WINTER ISLAND - BUILDING INSPECTION (2) C �
The Commonwealth of Massachusetts PECjtpKpt SE CITY OF
Board of Building Regulations and Slnnd4E LEM
( 4 � Massachusetts State Building Code, 780 CMR ������ O vt LEN.Vlar 201/
`Q Building Permit Application To Construct, Repair, RenOvat�pDLftiOlish a
[— One-or Two-Family Dwelling
This Section For Official Use Only
F' Building Permit Number: Dnte Applied:
JIM
Building Otticial(Print Name). SiynaLure' . . Date
SECTION l:SITE INFORMATION'
1.1 Property Addr 1.2 Assessors MAP&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 It) Frontage(It)
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,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yesE3
SECTION2: PROPERTY OWNERSHIP!
2.1 Owner'i4 ord.
•(UPf2.
N��hme(Print)— � City,Stale,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Altemtion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Wor
,c
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S ''fQther Fees: S �6 �"k(e
d. Mechanical (HVAC) S List: 1_
5. Mechanical (Fire S 'total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6. Tutai Project Cost: S ❑ Paid in Full ❑Outstanding Balance Due:
T1 l 1`�
' o
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supetisor License(CSL) l � -)_ �5 (
License Number E.e irali n Date
N;unc6f CC�SL 4bId r��, _ List CSL,rype(see below)
"lee tv`.-r`A lA Type .. Description
No.and Street
�-±�� U Unrestricted Buildin s tip-to 35,000 cu. 11.)
rS ''1� L/ �/Q] R Restricted I t2 F:unil D+vellin
City/Town,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
-rule phone &natl address D Demolition
5.2 Registered t10 a Improvement Contractor(HIC) t cpq L is � 1 ` o
( HIC Regltration Number Es vution Dote
HIC Con Nnme or HIC eglstr ame
Nu. andStreet _t5�-71J� Email address
City/Town, State ZIP TAe hone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.G F. 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
1,as Owner of the subject property,hereby authorize
t9 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: 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
\X'A contained in this application is true and accurate to
the best of my knowledge and understanding. /r
l �
Prim Owner's o ,\uthorizcd Agent's Millie(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 nag 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
+vwvv mass eov'oea Information on the Construction Supervisor License can be found at www.mass.�_ov�'d�s
2. When substantial work is planned, provide the information below:
'total floor area(sq. ft.) 4 ,(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_
1. "Total Project Square Footage"may be substituted lbr' total Project Cost"
J
CITY OF SALEM, MASSACHUSEM
1 BUILDING DEPARTMENT
' 120 WASHINGTON STREET,31D FLooR
TEL. (978)745-9595
KIMBERLEYDRISaOLL FAX(978)740-9846
MAYOR THomAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COM USSIONER
" 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:
(name of hauler)
The debris will be disposed of in:
�rh
(name of facility)
(address of facility)
Signature of applicant
��A�o
Date
° CITY OF S,:U-E.N•I, NL-1SS.ICHCSETTS
4 BuLLDL,IG DEPART�,W-NT
120 WASHNGTON STREET, 3ia FLOOR
TEL (978) 745-9595
FAx(978) 740-9M
ICI.\IB RI FY DRLSCOL L
5 NL'1YOR THonitsST.PiERRE
DIRECTOR OF PUBLIC PROPERTY/81:I1.DNG COMMISSIONER
1Vorkers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers
Anolieant Information Please Print Lee_Lbly
Value(Busire.i&Organirati,imindividu:d):
Address:
City/Blatt/Zip: v Phone N:
—,%rcjyou an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4, ❑ 1 am a general contractor and
- 6. ❑New construction
etployees(full and/or pan-time).• have hired the sub-contractor
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑Remodeling
,hip and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. workers'comp. insurance. 9. 0 Building addition
I No workers'comp. insurance 5. 0 We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.0 I not a homeowner doing all work right of exemption per MGL 1 I.0 Plumbing repairs or additions
myself. (No workers'comp. C. 152, §1(4),and we have no 12.�Roorrepairs
insurance required.) t employees.(No worker'
cutup. insurance rcquircd.j 13.0 Other
-AnY applittan tlwr ChV.kr box/I mWr]Iia fill YYI tile Ytt4un bo lowihowllla attic waskoiW mmpenrmlan policy information.
'I h,meuwnery who whmit This smtbwit indicating they are doing all work and then hire outside contractors mast submit anew amdavil indicating ruck
$'....rautum that ch vk Ibis but;mat anachod an addiliuml Aral showing the name orthe suboontactan and their workers'camp.policy inrumtatitn.
/unr art rurpluyer that!r pruvidluK Ivorkers'c unrpruradun lnsurunce jot my employers Halow lv the policy gird fob Nita
injurourion.
Insurance Company
Policy it or Self-ins. Lie. d: Expiration Date:
Job Site Address: City/Slaty/zip:
Atlach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage us required under Section 25A orb1GL e. 152 can lead to the imposition ofcriminal penalties of a
line up to SI•-500.00 and/or mu-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
arup ro S250.0o a Jay against the violator. De advised that a copy of this statement may lx: furwarded to the oftive of
Inccstigariuns al'the DIA for insurance coverage verification.
/du hereby certify under the palm and penalties ojprtjury that the injurmullon provided above is true mud correct.
li'ndlnre: Dater
1_'hunc A'
Of iciu!use only. Do nor write in this area,to be co tpleted by city ur to o/Jieiut
Ciry or Town: _ -- — Permidl.leense d__....
Issuing Authurily (circle one):
1. Buurd of Ileatth 2. Building Depatinlent i.Cilyffuwn Clerk 4. Electrical laspector 5. Phtnlbing Inapecrnr
6, Other
Cu0aU I'eno": Phone :I:_ I