11R WINTER ISLAND RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,i780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Ilse Only
Building Permit Number: Date pplied: /.;Z-a -��
V I Building Official(Print Name) Signature Date
`J SECTION 1:SITE INFO ATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
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Ma Number Parcel Number
1.la Is this an accepted street?yes r/ no p 1
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1.3 Zoning Information: 1.4 Pro. iopierty Dimensions:
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Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft) 1
Front Yard Side Yards I Rear Yard
Required Provided Required Provided Required Provided
1
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood!Zone? Municipal Rl,�site disposal system ❑
Public Er� Private❑ Check if yes ,
SECTION 2: PROPERTYOWNERSHIP'
2.1 Owner of Record:
�ZA G. /n2F �flLen l
Name(Print) City,State ZIP
rUe ^"-p / 7GP-/8s7
J Telephone Email Address
No.and Street
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑, Repairs(s) �❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other C+l'Specify:
Brief Description of Proposed Work': T i �7", //X
/r�2. XJe�✓ o✓s¢�
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
1.Building $ �• i. Building P rmit Fee:$ Indicate how fee is determined:
❑Standard C ity/Town Application Fee
2.Electrical $ ❑Total Proje A Cost'(Item 6)x multiplier x
3.Plumbing S 2. Other Feed: $
4.Mechanical (HVAC) $ List: '
5.Mechanical (Fire $ Total All Fees: $
Suppression) Check No. I Check Amount: Cash Amount:_
6.Total Project Cost: S 0 Paid in Full ❑Outstanding Balance Due:
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�CHLS ETTS
CITY OF S< '�,Etii, ti`I�NSS-
Bu"D;G DEPjRT%0:�T
120 W 6 I TON STREEr,3'°FLOOR
•\ � , ' I Ei.. (978)745-9595
g1.Y(979)740-984b
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KL%IBERLEY DRISCOLL ONW ST.PMPRE
MAYOR DOCTOR OF PUB C PROPERTY/grn.DLNG CO\L�IISSIO\ER
11�
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
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(lame of fac ity)
(address of facility)
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signature o permit applicant
date
.Jebri�:ttT.�rx I
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SECTION 5: CONSTRUCTIOµN SERVICES
5.1 Construction Supervisor License(CSL) �{'cj
�P� 4J �� � Ljcense Number Lz-L Expiration Date
Name of CSL Holder
List CSL Type(see below) !J
IType Description
No.and Sveet
U Unrestricted(Buildings up to 35,000 cu.ft.)
�.urJ-Ple} 1�10SS o/�M3 R Restricted 1&2 Family Dwelling
Citylfown,State,ZIP M Masonry
RC Roofin Coven
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5/.2� Registered Home Improvement Contractor(HIC) /S$873
xl 1146e. ) Gt2P ��o0r<"��G�" HIC Registration Number Expiration Date
IC C e� C Registrant Name /J «H�Q -yJ
No.and Street 3 Email address
.Solo,,, ice!-rtSs n�S?o 1Y?yam_ `/�ot°
Ci /Town,State,ZIP Tel hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and obmitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building ermit.
Signed Affidavit Attached? Yes .......... ❑ No......_...IO
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 matterssrrelan e to work authorized by this building permit application.
ri Owners Name(E etromc Signature) Date
SECTION 7b:OWNER'OR AUTHORIZ AGENT DECLARATION
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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 ki owledge and understanding.
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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 HIC Program can be found at
wwv,%.mass.gov/oc Information on the Construction Supervisor License can be found at wvwnv mass.aov das
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 NLkSSACHLSETTS
BUILD LNG DEPARTM&NT
• s A• 120 WASHING rON STREET,3m FLOOA
a T�i-11781)
745-9595
FEAIX )740-9846
KIN BERI-EY DRISCOLL THOIs ST.PIFARE
;yUYOR I �
DIRECTOR OF PUBLIC PRi PERTY/BL'TLDL*IG COS50SIONFlt
Workers' Compensation insurance Affidavit: Builders!Contractors/Etectricians/Pinmbers
Applicant information Please Print Leeibly
Name(Busim�Organizationilndividwl): �92yGt2 n��?�C7�
Address: Y . Z6.1—
City/State/Zip: SAT ,/Y/ SSS Phon tf: �r S 7y�s600
Are you an employer?Check the appropriate box: Type of project(required):,
I. I am a employer with 4. 1 am a general contractor and 1 6. ❑New construction 1
employees(full and/or part-tithe)." have hired the subcotunctors
2.0 1 am a sole proprietor or partner-
Misted on the attach d sheet: 7• [�Remodeling
ship and have no employees These sub-con rs have 8. f]Demolition
working for me in any capacity, workers'comp.ins imacic. 9. Building addition
[No workers comp.insurance 5. O We are a corporati to and its 10.0 Electrical repairs or additions
required.] officers have exere sod their
3.El am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
. c. 152,§1(4),and we have no 12.❑Roof repairs
myself.[No workers'comp
insurance required.]t s:mployces.[7`'o workers' 13.a-O
comp.instuance required.]
Any applicant that ctwa:ks box t/l must also fill out the section below showing their aor�crn'comprnsuion policy information.
'I lomcowne s who submit this affidavit indicating they ate doing all work and then him etxside contractors must submit a new amdavit indicting such
=Contmunon that chock this box must attached an additional shun sh- ins the none of tde mh�and the¢workem'—P.Policy infometion.
/um an employer that is providing workers'compensation insuranceTor ray employees. Below is the policy and fob site
information. y
insurance Company
Policy 4 or Self-ins.Lic.#: �iinS' �a�d// Expiration Date:/O O/ d/A
Job Site Address://R 1f27 City/State/Zip: 4�276
Attach a copy of the workers'compensation policy declaration pagle(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 3 2 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil petaltes 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 DtA for insurance coverage verification.
I do hereby certify un r tire pains and penaties o his ury that the itiformadoa provided above is true and correct
Sic I < -
Phone# c17�/ $%DOU
Okld use only. Do not write in this area,to be completed by ci or town ojftei'd
City or Tuw•n: _._ PermitiLicense
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk,, 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact.Person' _.____ Phone#:
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