1 WOODSIDE ST - BUILDING INSPECTION (2) � The Commonweaith of Massachusetts Town of
� r�"" Board of Building Regula�ions and Standards �.
� ` .��� Massachusetts State Building Code, 780 CMR, 7'"edition gwWing Dept
� Building Permit Application To Fo�struct, Repair, Renovate Or Demolish a �
Orrc or Tno�Fmriil�•D�re!ling
This Scction For ORcial Use Only
Building Permit Number: � n � � � Date Applied: ' 1 (�� �
Signature: � � �� t Q. � �
Building Co issioned Ins�ec�iortof Buildings Date
SECTION l: SITE INFORMATIOfV
I.1 Pr�ert�ddr �:' i. S� 1.2 Assesson Map& Percel Numben
dKi
Ma Number Parcel Number
I.l a Is this an accepled streeC?yes .� no_ P
�,} Zoning Informatlon: �.4 Property Dimensionr
Zoning Dis�rict Proposed Use Lot Arca(sq R) Frontage(R)
LS Build(ng Setbacks(R) �
Front Yard
Side Yards Rear Yard
Required Provided Required Provided Required Provided
t.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Informallon: 1.8 Sewage Dispoeal Syetem:
Zone: _ Outside Flood Zone? Municipal� On site disposal system ❑
Public�, Private O Check if es�
SECTION 2: PROPERTY OWNERSHIP�
2.1 �er'of Record: / ` w����� �
)Fk-��c �U c�f"
Name(Print) Address for Service:
/— �o1—;i l �- 6 /C3
Signature Telephone
SECTION 3: DESCRIPTIOtt OF PROPOSED WORK'(check all that epply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) � Addition ❑
Demolition Q! Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: �
Brief Descrip�ion of Proposed Work�: N'�W ��i}"e�P �/ �/00/.S � rPr'..OK- �F�U
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Esiima�ed Costs: Official Use Only
Item Labor and Ma�erials
1. Building E ,..� SOJ �� Building Permit Fee: $ Indiwte how fee is detertnined:
❑Standard City/Town Application Fee
2. Electrical 5 � 006 ❑Total Project Cost�Qtem 6)x multiplier x
J. Plumbing S . t�fQO '. Other Fees: E
4. �blechanical (HVAC) 5 � List:
5. Mechanical (Fire 5 ---� Total All Fees: E�
Su ression
Check No. Check AmouN: Cash AmounC
6. Total Project Cost E �� g� ❑ paid in Full ❑Outstanding Balance Due:
2� �l(+G�u72C7Y'�
�2� � p �
SECTION 5: CONSTRUCTION SERVICES
5.1 Lice�truction Supervisor(CSL) GS ��7� .—�� /.
Liccnsc Numbcr Exp ratw Date i
N�mc ul'CSL Hplder 1,� ��/ .
• L �� C-NtJ NV ��' �" C1s�> Lixt CSL Typt I�«bcluw)
q����� �J T Descri �ion
�j(O(�C.��N� Ih'� Q ��j '�7"I U Unresiric�ed u to 35,000 Cu. Ft.) �
R Restricted I&2 Famd Dwrllin
Signulure � N M1lason Onl
RC Rcsidential Roofin Coverin
Tdepho e � WS Rrsidential WindowandSidin
G11��3���6��l SF Residrntial Solid Fuel Bumin A liance Installation
D ResiJemial Demoliuon
5.2 Regi�tered Home Improvemeot Controctor(HIC) l,.� � J J r/
� ! 7�
HIC Com an Na e or HIC Re istrant ame Re istra�ion Number
o r rr r�o� 6F r1�` C-Y� G ro�.e.IAr�Z M-� !��y,��_
Addrtss �,/
V�� /-97�'37S-�j! 3' �Expira�on Date
Signatur Telephone
SECTIOIY 6:WOi2KERS'COMPENSATIUN INSUFtANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6)) i
Workers Compensation Insurance afTidavit must be compkted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signal AmJavit AttacheJ? Yes .......... ❑ No...........
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�. - , as Owner of the subject property hereby
authorize ro act on my behalf,in all matters -
relative to w a ed by this uilding permit application.
Si naturoofOwner Date
SECTION 76: OWNER� OR AUTHORIZED AGENT DECLARATION
�. , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behaif.
Print Name
Signature of Owner or Au[horized AgeM Date
Si ned under the ains and enalties of r u
IYOTES:
I. An Owner who obtains a building permi� to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contrecror(HIC)Program), will nof have access to the arbitralion
program or guaranry fund under M.G.L. a 142A. Other important,information on the HIC Program and
Construction Supervisor Licensing(CSL)can be (ound in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
. Total floors area(Sq. Ft) (including garage, finished basemenUattics, decks or porch)
Gross living area(Sq. Ft.) Habitabk room count
Number of fireplaces Number of bedrooms
Number of bathrooms Uumber of halUbaths
Type o(heating sys�em Vumber of decks/porches '
Type ofcooling sysiem Enclosed Open
3. "To�al Projec� Syuarc Foo�age" may be subs�iluted (or"Tutal Project CosY'
. . . . _� . ._z
. . . � � �� � � Page No. �of Pages .�
♦
Y' ,
a . .. n . ' . �r y"y . , y #tv ... . u�F�.
`�• + LEGERE CONSTRUCTION ' ''� �
r _ ,.<, m .
, �•�"Serving Customen With Qua/ity & Pride ` ' '
`�� " 15 CANNON HILL ROAD EXT. � ; ` '* °'`
�, - GROVELAND, MA O1S34 u � _ `� `� �b� �
, Cell 1-97&375-6431 r ; , , � - . , ���,
PROPOSALSUBMITTEDTO � � -. � .. � � � � � PHO ' . ' ' "' • DATE • . - „f"�` y
Nt�� � �oa= sia-6/oSil d �� � ° ;, , ��
STREET . �' � • . - . .. �JOBNAME ' , .. , , . � • ` ,.
l � c•Joocj .�; � " � e . . � . , � _ C����� s :C7`I`r'f+ � , �-(�. r ,. . . �����
CITV,STATE and ZIP COOE � , •. JOB LOCATION � . , ' .
. .. . .. . .. �.//� � r ' , " .:: h r ...� ,.�1
. . * �� ( "
J�3 P'�- /�: . , _
ARCHITECT .. _ .. „ DATE OF PLANS ��G ... � � / �`�S .. . t rt � JOB PHONE t, y i,
/ ��
l
We hereby submit specifications and estimates for
�Ci��� f nrtW�-� ��o
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d_�N� �t ����all r �,/ �I s b i rsolude� ; �s fil�c_ eMe o-G Pl f ex is�i�r� e,�bl r�s
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v
� r�ql/ n�e.�c e��N.� ���m� be�r�-(axta� t�-��ts sup�ed .b� ��'de��l�-s
�,c�ld��� ;�,� l��il v�v Are� �
��uMbcn�= N� 5tnsky �� si. �sV�.s, .�.r�fiesL- L,nak� �6� �;d��-b �,�.6v�,
��e�1' 1fl ar�o� h�b1 wA�/ i,.����
—�,��J 1.��'lor� : A d f ,���1�fifon� �6 a���
z ler>1"�ic ' nf� re�s� 1�°��rl � ;'nf �Ir�l� �afe-� :D��� ��� nM'�fow�ve�� .
�1� �� �,e�e �`n( Y i�'�fb^e rJ a re fl �t�eM�,e... A l I 6 {c�, ��S �- ie �a ���
� �✓i fG��S
�i��«alz �'iv,��l�s ' Ge�l�n�� �a_a��"b/�r ',1�.��v� w ���� e����'c. ,� r1��.
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W@ PI'OpOSe hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
dollars($ )�
Payment to be made as follows: '
All material is guaranteetl ro be as specifietl. All work to be completetl in a workmanlike
manner according to s�andartl practices. Any alteration or devia�ion fmm above specifications F�U[horized
involving exira cosis will be executetl only upon writ�en ortlers, and will become an extra Signature
charge over antl above ihe es�imate. AIl agreements con�ingent upon sVikes, accidents or
delays beyond our control. Owner to carry fire, tornatlo and other necessary insurance. Our NO�e:This proposal may be
workers are tully coveretl by Workman's Compensation Insurance. withdra n by us if no�accepted wdhin dByS.
ACiriP.pLanriP. �1 �r�pO.Sal —Theaboveprices,specifications �
and conditions are satisfactory and are hereby accepted.You are authorized to do the Signatur
work as specified.Payment will e made as outl_in�e1d abo,v�1 C� .
Date of Acceptance: - �� �' "� v / Signature
n ® Page No. of Pages
LEGERE CONSTRUCTION
Serving Customers With Quality & Pride
4s 4 15 CANNON HILL ROAD EXT.
1,GROVELAND, MA 01834
Cell 1-978-375.6431 ,
PROPOSAL SUBMITTEDTO':Z,'
'.* - ..
i;t
PHONE ^ ,".. ,. ,
DATE +•+ _ -
W,
r
STREET •+
JOB NAME .
i xe+...
¢
CITY, STATE. and ZIP CODE,
JOB LOCATION
,+, a {
ARCHITECT
p }•
DATE OF PLANS
JOBPHONE
-a x+"
We hereby submit specifications and estimates for:/
A IJ
kJA
K
dA14-Q, % /f ("2 riN,`rS�. .Ia K 0P 1��o a F
Wep/Propose /hereby to furnish material and labor — complete in accordance with above specifications,
(for
lthe sum of:
t!i / 0 � D 57 S dollars 7 V `.' ).
nt to be made as follows:
AN
'a ) X000 CAbir
411-rlfaterial ism guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications
involving extra costs wilt be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry tire, tornado and other necessary insurance. Our
workers are fully covered by Workman's Compensation Insurance.
Acceptance of Proposal —The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized to do the Signature
work as specified. Payment will be grade
asJputlined above.
Date of Acceptance: 9 Signature
,/ i
days.
M 1 1 Inti .'1 I
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12- W.Ne11 \t.1,IN 51:1LLt • 5ntl'\4, M.\\\.\t in III "197
I'1,I. Vs'1>95't5 ts 1' nx 9711-71, 1.446
Wurken' Compensation Insurance %tftda\it: Builders/Cuntracturs/Electricians/Plumbers
V ilnlC llhl.nlets:e)rpanl auinit'InJ1\�,luall: -bl
Gill�1'011 JA;0 &rell,
city, st:lrc. rip Gro vr_JF�Nl /%A L ! 2W Mone'" 5
\re you an employer.' Check the appropriate box:
. ❑ I am a employer with 4. ❑ I am a general contractor and I
engiloyces (full andiur part-time).•
2.X 1 im a sole proprietor or pamner-
ship:utd have no cmpluyces
working for me in any capacity.
I No workers' comp. insurance
rcquircd.]
3. E]I ;J111.1
nt a homeowner Juing all work
myself. tNo workers' comp.
insurance required.] t
haee hired the suh-contractors
listed on the inaclIcit sheet.
These subcontractors have
workers' comp. insurance.
❑ We are a corporation and its
officers lave exercised their
right of exemption per MOL
c. 152, g 1(4), and we have no
cmpluyces. LNo workers'
comp. insurance required.]
1'ype of project (required):
(,. ❑ New construction
7. Remodeling
a. ® Demolition
9. ❑ DudJing addition
10.0 Electrical repairs or additions
I I.[] Plumbing repairs or additions
12.❑ Rucsfrepairs
13.❑ Other
• t,p ..,g1LuW than checks but el must J160 tit tKil the W""" lwluw isiolvi ll then, wufkws cumpenWiwt Iwllsy nditrmatiun
' I Wmeuwmn whu suun+it this a1TIJavit inJie+una shay 4n Joins d1 work +11d then him uutsldn cauraetun musl .uhmil a new 41 f:Javil i.Ji".ny .,,h.
-C ,.nlr4culry thin shook this box mtW ntxhsd 4n 4eJllion+I .`ha -el Jluwina Ila meow of thn subwontrulun and their wurkan' ctvnp. r11J1cy mftlmtanon
/ um wt rrtrp/oyer that is prueiding workers' coinpenaffion intnrance %ur uty entp/uyerr. Be/oty ix floe pu/icy and/tib site
iofurntafiun.
Ir..uraocc Company Name: _._. - - -- -
1'oli.v a or Scif-ins. Lic. N: __... ... ___ Expiration Datc:
1oU >nc-lddress: _ __. City. Slaty Zlp:
.\trick at copy of the workers' compensation policy declaration puge.(showing the policy number and expiration date).
1'a11ufe to secure cuscrage as required under Sectiun 25A ul'>IGL c. 152 can lead to the imposition of criminal penalties of a
rim: op to il.5oo.00 antVur one-year imprisanlncnt, Js well 4s cis J penalties in the form of a STOP WORK ORDER and a fine
of op m S'50. 00 a Jay against the violator. He adv i.tcd that a copy of this ataicnfcnl may be fur,xirded to the Office of
In\:.n.,Jn.em of :lee 131.\ :or on.utance ;tn:rJgc totiti,Jtmn.
/ du hcri by tafijv Wider floe pa i e told poorhiec u%per%nry that the io%unnmion provided above is true atfd correct.
�/ 1 /0 1
t)/firiuf est only. /)a not ,rile in this arra, to be tumpleted by city up town ,],fitia/.
(av ur fate n: __.
Per mitiLiecnse At
Lsuing .\uihuray (circle nuc):
I. Ift,J rJ of IIv.JIh 2. lluddiu� ng).irtiuenl 1. (Ali"I'owu Clerk 4. Electrical Inspector i. Plumbing Inepcttor
6. Other
('lou act I,kf .. .. Phone tl:
Information and Instructions
N I.1 �s.lrhu..ctts Genesi Laws chapter 1 52 requires all etnplo)crs to provide workers' compensation for their cnnployces.
I'unu.mt to taus .tatuic, an rmpfgree is defined as " every pclson In rhe service ul anumher un.ler .lily .onttact of hire,
:.press or iinplicd, oral or it nfen."
\n : mpfuper I< defined as "an individual, partnership, associauou, corporation or other legal curry, or any two or snore
a the tofecooig engaged lit a joint enlerpnsc, and Including she Icgal rcpreseuranves of a deceased emplu)cr, or the
receiver or trustee of .at Individual, ptutnehhlp, association or other legal cnnty, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
Jwvellu)g huuse of another who employs persons to do maintenance, cuostruction or repair work on such dwelling house
or on the erounfis tic budding appurtenant thereto shall.not because of such employment be deemed to be an employer."
MGL chapter 152. $25C(6) also states that "every state or local licensing a);ency;sha8 withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
\dditionally, MGL chapter 15_2, 425C(7) states "Neither the commonwealth nor any of Its political subdivisions shall
anter into any cuntract for the perfom)ancc utpublie work until acceptable ew idenve of cu)lpllance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicanq
Plcase rill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and; if
necessary, supply sub-contractor(s) nante(s), addresses) and phone number(s) along with their ceriificatc(s) of
Insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP docs have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
.%ccidenfs for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The atlitlavit should
be retumcd to file city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their .
self-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till not in the event the Office of Investigations has to contact you regarding the applicant.
rlI ase be.quire to fill in the pennit/license number which will be saved as a reference number. In addition, an applicant
that must submit multiple permit license applications in any given year, need only submit one .affidavit indicating current
policy information (if necessary) and under "Job Site Address:' the applicant should write "all locutions in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city m- town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
I i.e. a dug license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
I h; t )I ticc of lavevti.plions would Ifni to dlank )l)u in advamcc for your cooperation and should you ha%c .my yuebtwns,
please do not hesitate to give us a call.
ncc Department's address, telephone and fax number
The Commonwealth of Massachuxns
Department of Industrial Accidents
0MCe of Invesdgadons
600 Washington Street'
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PRoPRERTY
DEPAR"I'MENT
.,
I I I - V-3 -4; );'J; I ,C 'i'S V: '64-,
Construction Debris Disposal .affidavit
(icwluiied lbr all demolition and renovation work)
In accordance n ith the sixth edition of the State Building Code, 780 ChIR section If 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit It is issued with the condition that the debris resultin.- from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
(name of iauler)
I he debris will be disposed of in :
l�ftIf _ _
(name of lacility)
l addresv of Ianlilyl
1 t7 d
,Ia1,�