11 WILLSON ST - BUILDING INSPECTION The Commonwealth of Nlassaehu/setts
��. Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CNIR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two Family Dtvelling
This Section For Qffici se Only.
Building Permit Number;' D A ed>.
Building Official(Print Name)
SECTION 1: SITE I ORNIATION -
1.lIP`rop rrt)y A;t1se� S 1, 1.2 Assessors Map & Parcel Numbers
II W f 11 11
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
PublicVNI_ Private ❑ Zone: /1_/ Outside Flood Zone? Municipal On site disposal system ❑
Check if yes❑
SECTION 2:, PROPERTY OWNERSHIP' '
2.1 Owneri o Record:
#'cl wner', WbviSaLAW_ P�pt)ooh I i-tn ti• 614 (o L
Name(Print) City,State,ZIP �t f
i:6 S FrV'e S� - "-.3f y- ` 1f1 LZ-Moy ' Sow It? S Q L w I
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ 1 Existing BuildingCg" Owner-Occupied ❑ Repairs(s) ;?(— Alteration(s) ❑ 1 Addition ❑
Demolition ❑-I Accessary Bldg, ❑ 1 Number of Units_ I Other 154 Specify: aQ
Brief Description of Proposed Work': SArif I .! t S $
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Official Use Only, .
Materials
1. Building $ $00 1. Building.Permit Fee. S Indicate how fee is determined:
❑ Standard.City/Toiyn Application Fee
F2 Electrical 30 Total Project Cost'(Item.6)x multiplier x
3. Plumbing tS 2. Other Pees: S
4. Mechanical (lIVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: S
/� Check No. Check Amount: Cash Amount:
(. 'l'otol l'ru,ject Cost: S ti e d d ❑Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL) Z
— 1/(�jp� 0.-S License Number Expiration Dute
Name of CSL I[older 0
5 e( '�
List CSL Type(see below) ,
No. a Street Type - Description
VP OA � ^ Al A G+f � 6 � U Unrestricted(Buildings u to 35,000 cu. ft.)
V R Restricted I&2Family DwellinS.
City/Town, State, ZIP M \lasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
[ Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor HIC) 11L
S l% � FIIC Registration Number Expiration Date
HIC Company Name or INC Registrant Name
No. and Street Email address
City/Town, State, ZIP 'Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L,c. 152. § 25C(6))
Workers Compensation Insurance affidavit mast be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached. Yes ......... No ...........
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) D, e
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
_r�rvt.-tom ,�w-tsm,, 1w� 121►% I� z
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the FIIC Program can be found at
�oww.m;us."ov%oca Information on the Construction Supervisor License can be found at www.mass.so�tlL
2. When substantial work is planned, provide the information below:
Total floor area(sq. Q.) _ (including garage, finished basement/atticS, decks or porch)
Gross living area(sq. fi.) _ Habitable room count
Number of freplaces--- Number of bedrooms
Number of bathrooms Number of halt/baths _
Type of heating system _ _-- _ _--- Number of Necks/ ponchos ------- --
1'ypeorcoolimgsysient__-- ---— Enclosed -Open —
3. ` F'otal Project Square Poohrge" may be substituted for' ord Project Cost"
CITY OF S.-1LE,Nt, UxsSACHUSETTS
t3uiLoo4G DEPARTJtENT
1 ' `" N• 120 VU.1sHINGTON STREET, 3° FLOOR
TEL (978) 745-9595
F.+x(978) 740-9846
KIN(BERL.EY DRISCOLL
ANYOR TwmAs ST.PtERRs
DIRECTOR OF PLBLIC PROPERTY/BUI DNG CONINUSSIONER
Construction Debris Disposal Affldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l L5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by;
� � �-eeC'- �
(name of hauler)
'fhe debris will be disposed of in
` fin M 6'r' '�
(name of facility)
(address of facility)
signature of permit applicant
IZII � I�Z
ilatc
CITY OF SAL.E.. I, NLUSACHliSETTS
t BUILDING DEPARTNW-NT
'r ja 120 WASHIINGTON STREET, 3"FLOOR
a� TEL (978) 745-9595
F.kx(978) 740.9844
KnfB RT RY DRISCOLL
MAYOR T HOMAS ST.PtERR8
DIRBCCOROFPUBLIC PROPERTY/BUTI.DIING CC%L%IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r ilicant Information Please Print Legibly
Name(Ousiivs&Orpnizaiioruindividual):/ e_,Y_ M )MO ✓ d V I
Address: n //- S�
City/State/Zip: PQ�t- t M)I' 0 11 b 0 Phone M:
Are you an emplayer?Check the appropriate oxs 'rype of project(required):
I.0 1 am a employer with 4. 1 am a general contractor and 1 6. �]New construction
employees(flail and/or part-time).• have hired the sub-contractor
2.0 1 am a solo proprietor or partner- listed on the attached sheet I I. ❑Remodeling
ship and have no employees These sub-contractor have S. ❑ Demolition
working for me in any capacity. workers'comp.Insurance. 9. 0 Building addition
(No workers comp. insurance 5. 0 We are a corporation and its 10.0Electrical repairs or additions
3Y��`,,,......,,,fff requirud.I officer have exercised their
. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repair or additions
/ `myself.[No workers'comp. c. 152,§44).and we have no 12.0"Roof repairs
insurance required.)t employees.LA'o workers' I3.0 Other
comp. insurance required.)
•Any applk d oat cbcxkt box et true,at.till out the uvliw batawthawing their workaa'compensation polivy infurmadon.
'I h"tnowtur who submit this amdavit indicating they am doing all work and then him"laid,contractor mart I,bmil a new amdavit indicating tuck
:Gmtrauton that ch«k this box most attached an additional sheet showing the name of the tubcontncWn and their worker'curttp.pulley information.
I um an employer that Is proyfding workers'compe»tadon Graurance for my employees Below Is the polfey and Jab site
informutfom 1 9
o, -ql 1 ` I
Insurance Company Name: Cur fir� e "`^{" w�\ \ � —t'a y_e_ 1Z t q Q w�
Policy 4 or Sclf-ins.Lic. d: Expiration Date:
Job Site Address: City/Staw/V
Attach a copy of the workers'compensation policy declaration page([hewing the policy number and expiration data).
Failure to sucura coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Off ice of
Investigations ofthe DIA for insurance coverage verification.
/du hereby certify under the pains uod peaulNes of par/ury Offal the hifunnwlon provided ubuve i�true uqd correet
IZ
Phone
U/)Icial use tidy. Du not tyrite in this army lobe rump/clad by city ur town n/)trio!
l City or Town: ___, _ Purmlt/1.lceme� `_
Issuing Auiliorily(circle one): --_-- _
1. Bourd of Health 2. Building Deparnnent 3.Cilytrown Clerk 4. Clettrlcal Inspector 5. Plumbing Inspector
6.Other
Contact Person: __. . ___ ._ Phone/h
��o�nn�'��&�a�ne� egu anon..
,✓� Office of�on3ume
---\_- HOME IMPROVEMENT CONTRACTOR Type.
Registration 4171141 DBA
V Expiration 211612014
-OTSOULASHOMEIMPROVEMENTSVCS.
im V
ALEXANDER MOUTSOULAS
11 "LLSON ST Undersecretary
SALEM,MA 01970 �. -y��Y
1 Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supcnisor e
License: CS 101740P
ALEXANDER S r4t)UTS0O, SI',_
5 Pine Street '
Peabody MA 01969
Expiration
1210512014
Commissioner