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WINNE-EGAN AVE BAKERS ISLAND - BUILDING INSPECTION --r I �- (Lf — SOS fit' 3's The Commonwealth of Massachusetts AA 1 Board of Building Regulations and ECEIVED CITY OF y ; ZONAL SERVICES Massachusetts State Building Code, C SALEbI Revised Nlar 20/1 Building permit Application To Construct, Repair, Rep�a3URr1�m�js0k One-or Two-Family DwellingLLuu This Section For Official Use Only Building Permit Number: Date Applied- Building Official(Print Name) Signature Date SECTION I:SITE INFORMATION 1 I Property Add ess: 11.2 \�s sor Parcel Numbers bt�tr�nl�- r3 A�l . gAKE23 )St" _ '—��—% — — I.I a Is this an accepted street?yes no Map Number Parcel Number i..i 'iuoing information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq fl) Frontage(11) 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Check ifyes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERS111Pt I O r�o'Ren� F, _ wg ri � Name( )Print FY, a IP q City,Suua ZIP 116 PI.rA3A(r sY' y-ra,- q - 363 g No.and Street 'Telephone Fntail Addross SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ E.xisting Building❑ 1 Owner-Occupied ❑ 1 Rcpairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of roposed Work`: Il.b L40 v� Iec� ou >7v IiES�p __ ��cc_ - -� .WOtlD_ F —w� Cd - Q ic71�• PLAe S{� .� eE SECrION 4: ESTbN1ArED CONSTRucriON Cos'rs Item Estimated Costs: Official Use Only Labor and �Ylaterials y I. Building $ 3 do I. Building Permit Fee: S_ Indicate how fee is determined: 2. Electrical $ O ❑Standard City/Fown Application Fee ❑'rota) Project Cost'(Item 6)x multiplier—__x_ 3. Plumbing S Q 2. Other Fees: S 4. Nfech:mical (IIVAC) $ List:_ 5. Mechanical (Fire Suppression) Total All Fees: �� O 6O Check No. _Check Amount: _ C'ash Amount 6. Total Project Cos[ S ❑ I aid in Full ❑Ontstanding Balance Due: S(_—=:NT• TU cO(vT-rZ-F)C-i ) CZ- I I Q, SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Esp'muon ate Name of CSL Bolder AL 1 -7� / iS 1 n 1 !. ('X'�•, �L 3 List CSL fype(sec below) V No.and Street �/ L'Jr.11`V /'�A7^Y IF-- No. Description �I r�G`fo 1//� ®I �g7 U Unrestricted(Buildings u to 35,000 cu. t1J 11 / " R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Mason ry RC Rooting Covering WS Window and Siding SF' Solid Fuel Burning Appliemces LL U oC Jo�C I Insulation 'I'ele hone Email address D Demolition 55.2 Registered Ho ( Home Improvement Contractor(HIC) 2 3' `S ( 31 2 7 06 L?E2 U y�^ Te' ` I-IIC Registration NLJ!at r Expiration Date I IIC r i any Name or li C I�egistr n ame 2 /� D9@i l 1 , / C� rr�{ 04rngrz@E451r- IAgSTO�t�Tterg, Qa") e".�r> `:�C-Tol^j d`f/�d�%7� Q 7g' / �3.O;L/ !:mail address City/Town,State,ZIP telephone SECTION 6: WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(NLG.L.c. 152. § 25C(6)) Workers Compensation Insurance affidavit must 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 R APPLIES FOR BUILDING PERMIT I� I, as Owner of the subject property,hereby authorize Y1L=�" 17C.L'�a] �e C 61 TCa— to act on my behalf, in all matters relative to work authorized by this building permit application. RCJWE cA �W, 6 16 Print Owner's Name(Electronic Signature) I Date 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 I ( LTEp�)ef- ��- Ceej 7-kA 6 1G �— Print Owner's or Authorized Agent's Name(Electronic Signature) p;ute 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. 1 d2A. Other important information on the FIIC Program can be found at www.ntass.gov/oca Information on the Construction Supervisor License can be found at www.m:us.eov/dnS 2. When substantial work is planned,provide the information below: Total floor area(sq. R.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. I1.)_ Habitable room count Number of fireplaces __ Number of bedrooms Number of bathrooms_ Number of halt/baths Type of heating system _ Number of decks/porches Type of cooling system_ Enclosed Open _ 3. "Total Project Square Footage"may be substituted for"Total Project Cost" I t CITY OF SAL.EM, A-u&kCHUSETTS OL'ILONG DEPARTMENT 120 7UHLNGTON S-mF T, }O F(OOR g , 1t.-L (973) 745-9595 KINMERLEY DRISCOLL FAA(973) 7-t0-9345 &L{YOR r-tows Sr.PiF-qtg Dt.ucTc)R OF PCOLIC PROPEQTY/aL:u OptG CONNISS[O'NER Construction Debris Disposal AftZdavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Coda, 730 CD,(R Debris, and the provisions of MCM c 40, S 54; section t t I.S Building permite# this work shall be is issued with the condition that the debris resulting from disposed of in S I SOA. roper a ply licensed waste disposal facility as defined by ,1,(CL c The debris will be transported by; y CAS1✓tc4 0A2rre- (none ot'hautcr) The dchris will be disposed of in C�0,a1,4 (name of t3cdity) ASS (JJ ess of facility) ' flyltJ fU(e ]CI'RII(dtlP(li.11l( —' r CITY OF SI:U_EN1, NL-1SS:ICHUSETCS 13L'ILDING DE.PARTNtr—NT 120 WASHNGTON STREET, art'FLoo?. T EL (978) 745-9595 F.kx(9 7 8) 740-98.16 KI\IBEIILEY DRISCOLL e tiL�YOR THoNwST.PIF-4 S DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLAISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Ptumbers Applicant Information Plcase Print I e ibly+ Name tllusiness OrOrginivalion'Individu:d): 77Ci/ pt r,/T���Trs Address: ,,1 City/State/Zip: L0 1Lq,I°`) C ItglA) Y 1 t Phonelt: q2 r� 1r no an employer'.'Check the appropriate box: 'Type of project(required): I am a employer with_5_ 4. ❑ I am a general contractor and I employees(full and/or part-time).• have hired the sub-contractors 6. ❑New conswction i 2.❑ I ant a sole proprietor or partner- listed on the attached sheet. l 7. ❑ Remodeling .hip and have no employees These sub-contractors have 8. (] Demolition working for me in any capacity, workers'camp. insurance. 9, ❑ Building addition (No workers'comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. (No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) r employees. (No workers' ctnnp. insurance reyuircd.) I1.❑ Other •Any applivam that chucks bux I I mwI also rill out the section below showing their workers'mmpsn cniun policy inntmmrton. 'I Inmeuwtwn aha suhmil this atndnvii indicating they are doing all work and then him uWside cuntmetora mtnl auhmil a new air,6 t indicting such. $\vomctuo thus chuck this box mica anachcd can addidunal shut showing Ilse mmrie of tho sub.vntncWn and their workers'comp.policy inrormation. I ant an employer that is providing workers'eumptstu,eattlon insurance for my employees. Dtloiv la the policy mad job,dla insurun"C a7N f eo C ri y—r'Y tom. .l� Insurance Company Name; �c� 'fr�J p_I ��i'' rm�t Policy d or Self-ilia. Lie. d: D 7,r 7 D© I© _ 7`,'_� Expiration Date: Z Job Site Address:0)r�rJ e-.'- �G I�It AF v � .City/Stitt:/Zip: Attach a copy ul the woricers'compensation pulley declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 23A ufMGL c. 152 can lead to the imposilion of criminal penalties of a line up to S1,500.00 and/or une-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S230.00 a day against the violamr. Ile itlyked that a copy of this statement may be furwarded to the Oilice of InNv!-ngutiuns oldie DIA fo insurance coverage verification. - 1 do hereby ce Iif III, t/e pail 'and penalties of perjury that the hrfuruottotr rovfded buve '.v true and correct. ,i n t uc ;Pd, Phone,�: 7$ �k�6 0 Ufliciul use only. Do not write ire this area, to be completed by airy ur town njjicial City Or Town: _ _ Permit/Llecnsc g Issuing Authority (circle one): I. Board of Ileallh 2. Iluihllrlq Depertntcnt .l.f.itylfnwn Clerk 1. Electrriai Inspector 5. Plumbinj, In.apceior b. Other C'unlact Perim):_ Phone B: , ey r, 67 YoPeS7 Ul ♦ Ro t6' �Iu 11 3r 3S F-f/-JOrJ�NS(ET �5 - Ye z Q. -�l NNE F- N 9 ✓F,1 vE �ko Pe S�.9 s►i E j7 FocZ Rog, 27 ��gE 5AY�,ERs ISLAr-31 SA�.6 ►'� �'IFtSS .