19 WINTER ISLAND RD - BUILDING INSPECTION Sir, .,.A
/ I The Commonwealth of Massachusetts
A h Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Oft al Use Only
Building Permit Number: D16 Applie .
LAW_Z
Building Official(Print Name) Signature Date
SECTION 1:SIT INFORMATI
1.1 Property Addres • Ass &Parcel Numbers
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(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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: {
_1�KYv' \(k\Gv1t . Sr�12w� b 1t110
Name(Print) D `* City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. 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 (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1�S(5 11 Paid in Full 13 Outstanding Balance Due:
SK'C!0 5: CONSTRUCTION SERVICES
tp Sp�isor License(CSL) � �}
U ` W ��.,� S�� License Number Expi ion Date
t$ SL Holder
k.G\1O List CSL Type(see below)
No.and Street Type Description
(� U Unrestricted(Buildings u to 35,000 cu.ft.
'C7AV RY'\ �� o �� Restricted 1&2 Family Dwelling
City/Iown,State,zip I M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
\-,:i : \\ iiG ,., 5l
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Street Email address
ti-, \,1L^(N . 7 ' Cam_ Uwti 51Y �'
CityTown,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.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 APPLIES FOR BUILDING PERMIT
I,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) 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 accu t to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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 Number of half/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"
- - -- CITY OF SOU ENN N'IASSACHUSEM
BtiuDIDIGDEPARTSI�1T
�r+n 120 WASHINGTON STREET,Sao FLOOR
TEL (978)745-9595
FAX(978)740-98"
Ki\fBFY.LEY DRISCOLL
MAYOR niobw ST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%MIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leffibil
Name(BusincwOrpani:ationlindividual): \A
Address: �!
City/State/Zip: !v� Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
J�a A
1 am a employer with?� 4. 0 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-tithe).' have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
ship and have no employees These sub-contractors have g. 0 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
required.] officers have exercised their ME]Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] 13.0 Other
•Any applicaa That chocks boa A must also rill out the section below mowing thew workew'compansation policy infurmation.
t I lomeowoen who submit this affidavit indicating they are doing all work and then hire owids cont w3m mot submit a new affidavit indicating such
:Contracmn that chalt this has must atlachal an additional sheet showing the name of the subwntsacton and their wodcas'comp,policy infarswdon.
I am an employer that Is providing workers'compensation insurance for my employees. Below Is the policy and fob site
information. (�
Insurance Company Name:_ -
Policy#or Self-ins.Lic.#: C OU�� ��� Expiration Date: I )
Job Sire Address: nj City/State/Zip.— ( t
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date}
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as wall 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 Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify adder the pains and penalties of perjury that the h!rormaNan provided aboveIs truuee and correct
i•n tore: �Alll� Date'
Phone#:
OJf9cial use only. Do not write in this area,to he completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Aeallh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
L
CITY OF S. .E%l, TNLkss.ACHUSETTS
BUMDLNG DEPARTMENT
120 WASHINGTON STREET,YD FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KIJIBERLEY DRISCOLL
MAYOR THoma ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUUMING CONMUSSIONER
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 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:
(name of hauler)
The debris will be disposed of in :
(name of facility)
5tv�4 , S.�
(address of facility)
vi
signature of permit applicant
—
date'
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