1 WOODSIDE ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts Town of
Board of Budding Regulations and Standards
a� Massachusens Slate Building Code. 780 Ch1R. 7'"edition Building Dept
Building Permit Application To Construct, Repair. Renovate Or Demolish a
Onr- or Tiro-Fumt(t Ditriling
This Section For Official Use Only
•� Building Permt Number Date Applied:
Signature: — /v
Budding Commissi r/Insprctw of Buildings Vale
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I lel t�.l �s� 51
1.Is Is this an ecce ted street'?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Ana(sq R) Frontage 1ft1
1.5 Building Stlbncks(n)
From Yard Side Yardo Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:I c.40.154) 1.7 Flood Zone Informatloe: 1.8 Sewage Disposal System:
Zotr: _ Outside Flood Zone? Municipal)B( On site disposal system O
PubliaA Privam O Cheek if s0
11
SECTION 2: PROPERTY OWNERSHIP'
01
2.1 Owner'of Recor
Ta knv 4 T NCL Oh¢ MA
Name 1�
Address for Service:
(aD-;L� SID - (e/O.S
sign -- Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek SH that apply)
New ons tion O Eaistin#Building I Owner-Occupied O 1 Repairs(s) O Alteration(s) Addition O
Demolition > Accessory Bldg.O 1 Number of Units I Other O Spectty:
Brief Description of Proposed Work': t^ ,c--
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offleld Use Only
Item Labor and Materials
1. Budding f S p I. But Permit Fee: f Indicate how fee is desermined:
O Standard City/Town Application Fee
2 Electrical S Too O Total Project Coss'prem 6)a multiplier ■
J Plumbing f g 000 2. Other Fees: 11 j
1. Mechanical (HVAC) f List: v (./ 6
t Nechanicai (Fire S Total All Fees: f
Suppression)
Check No. _Check Amount; Cash Amount:_
h Tots[ Project Cost S /0-7 3,SQ 0 Paid in Full 0 Outstanding Balance Due'
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL) -d S 701
,,
N�rpe Yr CSL' Hylder License Number� � � � ( E.pt triton ate
List CSI. Type(n'e hitow)
A.�Inra o T Description
/�{ Ol 01,934 U Unrestricted(up to!3,000(afl
St t R Restricted IA2 Family Dwellin
sf— S— N ata only
RC Residential Roofing Covering
Tclephone w'S Residential Wmdow and Sidinst
SF Residential Solid Fuel Burning Appliance Installation
D Resttknnal Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC ompany Name or IC Relliislrml untie Registration Number
A /ac_pao ON I Lt e-x / �9 e)A � Mil bl ���I
Ar
- �'/? `�-3✓7,'—d N 3 Expiration Date
Sisnv ,) - Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52.1 2SC(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 AMdavit Attached? Yes..........O No...........E r
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.
SignsiumofOwner Dae
SECTION 71b:OWNER'OR AUTHORIZED AGENT DECLARATION
I. -L-0-' ,as Owner or Authorized Agent hereby declam
that the statements and in omnation on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
icy F� -c.G2-
print
Sispratuni 03mi Authorized Ali
(Signed under the pains and penalties of r
NOTES:
L 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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110 RS,respectively.
2. When substantial work is planned,provide the information below:
Total noon area(Sq. Ft.) (including garage, finished basement/attics.decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Nbmber of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Type of heating system Number ofdeckst porches
Tspeofcoolingsyuem Enclosed Open
1 "Tool Project Square Footage"may he suh,tituted for"Total Project Cost'
it
CI1Y OF S.U.E.NI, 3vLkss.kaiusETTS
BL UMLNG DEPART5111UNT
•
120 WASHINGTON STREET, )no FLOOR
TEL (978) 745-9595
FAX(978) 740.9846
KI-tBFat FY DRISCOIL
MAYORIkOSW ST.POh!StltJ<
DIRIICTOR OF PLecIC PROPERTY/gt:ILDING CM005SIONEI
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectrlciantiPlumbers
Annllcant Information / \ plea.. VrIn11 aibly
Vatne Iauairrna,OrtytOrarionlrrdrvadwl): ���"�`�',.� L I�l,�ip
Address: /S C-4�N"rj Ply J ext �,covel�ti� M�1 Dl $3�4
city/statraip, 6vck,eIAA, rM of gay phone M: 7fT-37�— 43I
%re you as empleyer!Cheek the appropriate boa:
Type o1 project(regtatred):
I.❑ 1 am a employer with 4. ❑ 1 am a gtnuxal contractor sod 1
employee.(full and/or pan-time).• have hind the sub-contyacters 6. Now construction
2. I am a sok proprietor or partner- listed on the attached shave: 7. ®Remodeling
.hip and have no employees These sub-contractors have g. ®Ikmolition
wonting for me in any capacity. Worker'comp,inauaoou q, C3 Building addition
(No workers'comp insurance S. ❑ We are a corporation and its 10. Electrical or required.) of7leers have exercised their ❑ repairs additiore
).❑ 1 am a honrrnwter doing all work right of exemption per MGL 11.❑Plumbing repain or addkkns
myself.(\'o workers'comp. e- 172,11(41 and we have no 12.0 Roar repairs
insurance required.)t employees.LNo workers'
COMP.insurance Mquind.J 13.0 Other
Any appuraal this duces baa Of row alto no war use merino boloor afn.iy nate,was .cwmliews lom policy ingion"arloa
I t.nreuwnea who sub"ads aeldavk indicatesawry ee doing all wok ad ten him auui`a somersea rOmw.hark a mato aMdsvk indtoring
n nonsafe
<'.+nrraora this cheek Otis be aerachd an ad.mond alarm showing ea noon,otos eAsrYradare W,hair tomo.'comp.Policy idtrosnaae
!use ere rerp/oyer that b providlnnr workers'roarpenrsrbe lese►ea cep fer my csplayaaat Below/s 160,11911M andM site
/rrformadm
Insurance Company Name:
Policy 4 or Self-ins.Lie.N: Expiration Date
!tib Sire Address: City/State/Zip:
Attack a copy of the workers'compeasadoo Polley deck dist pap(skewing the Pak7 number and expiration deft).
Failure to secure coveraie as required under Section 23A of MGL c. 172 can lad to the imposition of criminal penalties oft
fine up to S 1,300.00 and/or one-year imprisonmenct as well as civil penalties is than form of a STOP WORK ORDER and a fine
Of up to 5230.00 a day against the violator. Its adviser)that a copy of this statement may be furwarded to the Office of
I nvc,ngatiuns of ilia DIA for insurance coverage reaiticaiioa.
l de hereby ramify ado tho pedes and peirolNes 01,01#4407 that'At inforaratlos provided above is true and correct.
la
7.
Pan a �5 -- 6N31
I nJJlcio!nae only. Oo nor wail ie Chir.rear to be curnp/itd by airy w rove a/�lriaLJImpector
Cary err fawn: YrrmiN.lccnre N
i
Issuing Authurily(circle tine):
I. Ituard of Ilvallh 1. Ruilding Departanent I City/roan Clerk J. Electrical lmpector S. Plum
6.1)t her
l.ntl acf Person:__ ._ _. Phone N:
,S CITY OF SALEM
PUBLIC PROPRERTY
V DEPARTMENT
?*s ori
tl '•Nlw I'1 I
\I .U'N I'C��.1+111.\L:,LV SI'I(LET rr SAI 1'\I. SfAsi II Ill
1'FI:
978-7434395 •I:,%,c:918-74(}v846
Construction Debris Disposal Affidavit
(required liar all demolition wid renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N 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
I 11. S 150A.
The debris will be transported by:
t namc of IlaNIto
The debris will be disposed of in
(name of aci Ity)
(address of Facility)
I nat of >,ennit applic t
date
Jlassachtiutts-'Uclrartmcnt oC Public Saf'
1 Board of Building Resrulations and Standards
Construction Supervisor License
License: CS 85701
Restricted.to: 00 ''
- ru
JEFFREYL LEGERE.i
15 CANNON HILL RR EXT
GROVELANO, INA 01834`
Expiration: 7119/2011
('nnmiseionrr Trtt: 1159
y
® 0 Page No. of Pages
LEGERE CONSTRUCTION
Shying Customers With Quill fy 6 Prlo*
15 CANNON HILL ROAD EXT.
GROVELAND, MA 01834
Cell 1-478-375.6431
PROPOSAL SUBMITTED TO . II PHONE
�0
STREET I JOB NAME �^
a N� Y tc0y)Z/ AN-0c�t�_
CITY,STATE and ZIP CODE. JOB LOCATION
ARCHITECT `..F ,'w s, „^, ,'"„'.,`, DATEOFPLANS JOB PHONE
f
We hereby submit specifications and estimates for
r
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UU n�ciUdin
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ki-�c1�..<..� s7r�►t� c��s�,W�sl-.er -. Eli so all b�Se- bu�� ll�,..eRt �s -l-u be �,�stF-yleel
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All sNsdlPjfiur( ¢L) be Macode � d �'r` '4r vArled
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it btl h-bn 451 t^/I,44A I x 1 oZ f rw cJ t�/A,e l X �7(fr,/or"i C,
[QAk 7r-eill 4 jeA ;l/ NRt
We Propose 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 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 Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our Note:This proposal may be
workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days.
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 lbe made as outlined above.
Date of Acceptance:l�+'0—' l V Signature
® ® Page No. 1 of 3 Pages
LEGERE CONSTRUCTION C 5 V� 100
Servlog erN7Quality& Pride
15 CANNONCustoms HRLLth ROAD EXT. 117G 4F Jc(/ JCJg
GROVELAND, MA 01834
Cell 1-978-375.6431
PROPOSAL SUBMITTED TO PHONE DATE
STREET V JOB NAME `
I >W oud Sim st 'aN� Flook/AttiC /ze(hocO
CITY,STATE and ZIP CODE JOB LOCATION
54)19,x . rkR. , 0/77
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for M tr I r' N d Y' DD feMDae,
eMoII- ;iOJ _ /3otl. /pons
{7 /-o jx dP,nnoli Attic. }ro be bro(jow1' r;3l.fi
cdC-Aqi `o 5-f'0d S _ -
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CA1b
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We Propose hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
).
Payment to be made as follows: dollars($
All material is 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 Authorized ,
involving extra costs will be executed only upon written orders, and will become an extra Signature .
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our Note:This proposal may be
workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days.
Acceptance of Proposal -The above prices,specifications
and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature*�t4
work as specified.Payment will be made as outlined above.
Date of Acceptance: a y qg, Signature
• ® . Page No: _ 2 of; Pagesy,`
LEGERE CONSTRUCTION z-0
Serving Customers With Quality & Pride
15 CANNON HILL ROAD EXT. '
GROVELAND, MA 01834 4
Cell 1-978-375.6431
PROPOSAL SUBMITTED TO PHONE DATE
STREET • - JOBNAME , *+
CITY,STATE and ZIP CODE ". " • r ''.'. JOB LOCATION
S P)\,e
ARCHITECT r nz .DATE OF PLANS , + ^x JOB PHONE s
We hereby submit specifications and estimates for:
tC kktJ : N es0 Kr¢c 1�e +_0 �e i N 5--Hl l�e w t 11. c_,as b .r Wets a_�_-
OEvN424Cs' CkQIII ce.. J- k4c:,,IV\ iNRte_ Cc,01,ft•e2 f-o f
?"'I i Ar-f- = fl I I N e f.J A C-e As 1 J-0 fie. D. , M ed t q t N t-c U-J I+kN- 0 ww-,F-s
Ckoyce_ a-F coloy-S,
Alt (AcfjrTs -f'L)
We Propose hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
3(7,000 S21-NH dollars is /D7, wSr-u ).
Payment to be made as follows:
30 fxX� Pleb/dnh �ZUu4� /�JDyo Cato-Net<
C) nJC �1 N7, sV rJ <-u Mplet! 0
All material is guaranteed to pr as specified.a All work to vi completed in a workmanlike f�
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature / h
charge over and above the estimate. All agreements contingent upon strikes, accidents or
This pro osalUay be
delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our Note:
workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within / v days.
Acceptance of Proposal -The The above prices,specifications
and conditions are satisfactory and are hereby accepted.Ydu are authorized to do the Signature
work as specified.Payment will be madHs outlined above.
Date of Acceptance: aC (k Signature
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