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17 WINTER ISLAND RD - BUILDING INSPECTION c.ns i-c The Commonwealth of Massachusetts EPS) Board of Building Regulations and Standards RECEIVE© �rITY OF Massachusetts State Building Code, 780 ECTioNAL SER ICEs5ALEM Xevise<l il4nr 2011 Building Permit Application To Construct, Repair, Renovatte11Oyr�Dtn1Wsh�ej 23 One or Two-Family Dwellin LL This Section For Off 'al Use Only Building Permit Number: D e Applied: I Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION L1 Pmpty Ac/dress: 1/u / S 1.2 Assessors Map& Parcel Numbers L In Is this an accepted street?yes .—/ no klap Number Parccl Number 1.3 'Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area(sy tl) Frontage(Il) 1.5 Building Setbacks(R) 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 if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownerl of Record: 7 e /I/_y <� c? �nn M/k o/9 7 0 Name(Print) �� City,State.ZIP l9 w/N{-er- 37S( eP22 Y-1K 3/ 7 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:__ Briet'Deescciption of Proposed wo rk ': /j'�JQ C �j,� � '�. 1�y y --IrNf-!Y_- �2 tA/r„-•_l+iiyy_I�_—!\.2-�.�9-�D - SECTION 4: ESTINIATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials - I. Building $ D 00 I. Building Permit Fee: $_,�,�Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee `� ❑Total Project Cost'(Item 6)x multiplier x_ 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (I IVAC) $ f- List:_ 5. Mechanical (Fire $ Suppression) Total All Fees: S_ Check No. _Check Amount Cash Amount: 6. Total Project Cost $ (�(� at) ❑ Paid in Full ❑ Outstanding - Balance Due:/ lh lee, T B P u (,off T(3a 9 7� S-9 a l�S SECTION 5: CONSTRUCTION SERVICES 5.1 Construction'Supervisor License(CSL) t � 07065'7 )/r� 2 c� /� NaN�(/ G �a21� ^'^p�,t License Numbc;r /N—xpiratiun Date CSL 1-lo der List CSL Type(see below) `� 3 Nola Street `` ""3 Type Description /✓u• ��J 0! 7srf U Unrestricted Buildin s u to 35.000 cu. ft.) City/Tow ,State,ZIP Restricted 1&2 FamilyDwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances O �J� I Insulation Tcic hone Email address D Demolition 5.2 Registered Home Improvement Contractor(FIIC) HIC Registration Number Expiration Date FIIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP 'telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(INLG.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 AUTFIORIZAT[ON'TO BE CObIPLETED 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) Data SECTION 7b: OWNEW 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 th's. plication ' rue and accurate to the best of my knowledge and understanding. 2 Zg A01Print Owner's or Authorized Agent's Name(Electronic 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 HIC Program can be found at �aww.mass.gov/oca Information on the Construction Supervisor License can be found at www.ntass.eov/dps 2. When substantial work is planned,provide the information below: "total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. ft.)_ Habitable room count_ Number of fireplaces_______ Number of bedrooms _ Number of bathrooms_ _ Numberofhalf/baths Type of heating system_ Number of decks/porches _ Type orcooling system___ _ Enclosed Open _ 3. "Total Project Square Footage"may be substituted for"total Project Cost" .l M CITY OF SiU.EM, NLUSACHUSETtS ' — BUILDING DEP.1R'1->lE.\T 120 WASHLNGTON STREET, 3"'FLOOR T'EL (978) 745-9595 F.A-x(978) 7.10-9846 Kl\IBERLF-Y DRISCOLL "',k-kYOR T HO&W ST.PluRB DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER Workers" Compensation Insurance Affidavit: Builders/Contractor.vElectricians/Plumbers Applicant lnformatinn /ye tom// Please Print Le fblV .Name (Ilusinca0rganiralitiwlndividual): �t/I OQ�i/ee.k Addrdas; 4S e P�✓�� City/State/Zip: O/ 75q Phone a: 9 7,,'� 9q Arc you un employer?Check the appropriate bus: 'Type of project(required): I.❑ I a a employer with 4• ❑ 1 am a gcnoral contractor and 1 6. ❑New construction nIplayces(full and/or part-time)." have hired the sub-eontractorst 2. I coma sole proprietor or purtner. listed on the attached shcet. I �• ❑Remodeling ship and have no employees These sub-contractors have 8. I] Demolition working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition (No workcn•'comp. insurance S. ❑ We are a corporation and its required.) officers have exercised their 10.Q Electrical repairs or additions 3.❑ 1 am a homeowner doing all work fight of exemption per MGL 1 LEI Plumbing repairs or additions myself. (No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.) t employees.(No workers' 13.Q Other /` cmnp.insurance required.) Any uplumuulul chcuke but OI must also rill out the union below showing(heir work,,-compensation policy mrutmmlun. r y 'Ilomusw'rw•n who suhniii this alrldavit indicating lhry am doing all work and than hire outside conlmclots most suhmit a new antdavit indicatiny'sW, V tf k mumetun Ihut chsxk this box must auachar can uddiliurul:hu•t showing ilia n:une of fhe mbaentndon and ihtir work 'wmp.policy infunnmion. Jr ant an earployer that is provfding lvorkers'cunspensarlon le.turancer for my employees. delete is tlla Polley mtd julislle,S. ' a I in/ruasution. Insurance Company Name:, L( �_..l�S Policy 4 or Self-ins. Lio, d: /_ Expiration Date: Job Site Address: Li k///I/-�e.r City/stale/Zip: Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date). Failure to secure ewvemge as required under Section 25A of bIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 und/or one-year imprisomnent,as well as civil penalties in the forth of a STOP WORK ORDER and a line nrup to S_M.00 a day against the violator. Be advised that a copy of this statement may 1w f-urwarded to the Office of fit vcsl igaiiurtt u(llie DIA for insurance co vemgc vcri ficai ion. /du hereby rertlfy corder l�l/r�pains un re t Ir/rs�ofnperjury titer the infurmarlen provided ubuve Lv rr a and correct Si••n lnlre l�i� Date: Ofliciul use only. Da not write he this area,to be cumpleted by city ur town ojj7eiaC , I City nr'fuwn: _ _ _ Permit/1.Icense N Issuing Authority (circle one): - - ---- --- i 1. Guard of Ileahh Z. Buiidln;; Ilepartwe'" .1-Cit ylfnwn Clerk 4. Electrical fuspector 5. Plmul)ing Inspector 6. Other Cunfact Person: Phone:t: I evb QTY OF SALEM, MASSAMUSETTS efr +� BUILDING DEPARTMENT 120 WASHNGTON STREET,3m FLooR TEL. (978) 745-9595 KIMBERLEY DRISCOLL FAX(978)740-9846 MAYOR THomAS STTIERRE DIRECFOR OF PUBLIC PROPERTY/BUILDING CONMSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: ���// �2 f�i ��,�� �/� co lugs -F- ,r��P��F-✓' � bv� � (name of hauler) The debris will be disposed of in: d (name of facility) (address of facility) Signature of applicant Date ent of public W t} ,4 I;� Massachusetts - gu ations and stands"' I Wi Board of Building `r y r i Consiructinn Sup' } License: CS-070657r 'ALDEN -` 3ARLIls1GTONMA 02476��� ' a ExPlfation j O1E1dIZ015 .� ? Comnvisioner k�