2 WOODSIDE ST - BUILDING INSPECTION C/e —4F 317
y\ The Commonwealth of Massachusetts
j 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
�_.
;Tlrie 6®®tionFor 9€ficial -nly.,
Building Permit Number f Date plted:v
Building Official(Print Name) Signature D' ate
3 >
SECTION l: SITE=INFORMATION
=4
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1a 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(ft)
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 OWNPR9HTE1�
2.1 Ownerl of Record: / n l/zp
AA </ d RiOJ/J�fJ
Na (Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK- (check all that apply)
New Construction ❑ 1 Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work": r
: b SECTION A:EST_IMATED CONSTRUCTION COSTS ,
Estimated Costs: '
Item Official Use Only
Labor and Materials
L Building Permit $ Indicatehow fee is determined:
1. Building $ ,:-g ., ,.. , ,
2. Electrical $ ❑ Staudard CitylTdwn Application Fee "
❑TotalBrolect Cost (Item 6)�(multtpher z- `
3. Plumbing $ 2 Other Fees $
4. Mechanical (BVAC) $ Listc
5. Mechanical (Fire
Suppression) $ Total All Fees $
Check No Check Amount Cash Amount `
6. Total Project Cost: $ :0 Outstanding Balance Due '0 Paid in Fult
SECTION 5: CONSTRUCTION SERVICES •'
5.1 Construction Supervisor License(CSL)
n&k Jqq License Number Exp ratio Date
NameHolder'
List CSL Type(see below)
/ ijC- �dha C � '
No. and Street
U Unrestricted(Buildings up to 35,000 cu. ft.
Ci /Town, State,ZIP v!7 R Restricted 1&2 Family Dwelling
Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Y' I 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /012 Zi)- /
kt( C- dl A, HIC Registration Number piranon Date
HIC Company-Name or HI .strant Name
/<< !-er�Gx
W,�d�Str Email address
City/Town,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 de ' of the Issuance of the building permit.
Signed Afdavit Attached? Yes .. ....... ❑ No........... ❑
SECTI-` , . ER AUTHORIZAT ONrTO 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) ate
SECTION 7b: OWN] Rr,OR AUTHORIZED AGENT,DECI 1RATION r,
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 knowledge and understanding.
�7/L1,v in /(6�VK din /-� ti
not Owner's or Authorized Agent's Name(Electronic Signature) Date
u 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.Triass.gov/oc Information on the Construction Supervisor License can be found at tivw4v.mass.eov%dns
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 Sm—EN12 Nass.,iCHL'SETTS
BUILOLNG DEPARTSIEDIT
t 120 WASHIINGTON STREET, 3'o FLOOR
TEL (978)745-9595
FAx(978) 740-9846
D jI,tgFRT G.Y RISCOLI.
MAYOR IL THOMAS ST.PtERRB DIRECTOR OF PUBLIC PROPERTY/BUB=NG COhlIMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t slicant information Please Print Legibly
Nalne(Busincs*OrgtnizationAndividual):km
Address:/q, /2 -
City/State/Zip:`,/)d-44W/i/ M,*- � Phone f/: A'7
Are nu an employer?Check the appropriate box: Type of project(required):
I, am a employer with 7 4. 0 I am a general contractor and 1 6. ❑New construction
Kemployees(tail and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers'comp.insurance. g, 0 Building addition
(No workers'comp.insurance S. 0 We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,$1(4),and we have no 12. oo
insurance required.)t employees.(Ivro workers' 13 IJ f repairs
comp.insurance rcquin:d,j
;Any applicaan that checks boa el must also fill out the sdion below showing their work ns'compensation policy infnmation.
f Ih"cowners she submit this aMdavit indicating 1hsy ore doing all work and Ihon him outside canitactof moat submit a new aMdavil indlcating such.
:Contmatoo that Omit this box most attached an asWillusud sheet showing the nasne of the subaontracton and their workem'comp.put icy infomution.
l am an employer that is providing workers'compensadon Insurance for my employees. Below Is t/a policy and Jab site
iaformadom
insurance Company Name: `
Policy d or Self-ins. Lic.''9:_"/7O//O`,/7d /-ad/ 7. Expiration Data:—
Job SiteAdthcss:2 (O!/���'f�G��17" r CilylStatr/Zip:,1�Q��/rs
Altach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwardud to the Office of
Investigations of the DIA fur insurance coverage verification.
I do hereby crrt y tinder thspa fi rand penu6les of perjury that the infarmudon provided
ub /a ss r e and correct as
j'�. .I n /ti Dare:
4 /sl /1'
QJJirial use otdy. Do not wrire in dtb area,to be completed by city at,town offlaol
City or Town: __For mittiAcense
H
Issuing Aulhurily(circle one):
1. Bourd of Ileallh 2.Building Department 3.City/fown Clark 4.Electrical Inspector 5. Plumbing inspector
6.Other __
Cunt act Person: Phone tl:
CITY OF SALEM, XL-�SSACHL'SETTS
BUILDING DEPARTnt&NT
A• 130 WASHINGTON STREET, 3AD FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
(I,,,{gFRT F.Y DRISCOLI
gAYOR TT osw ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLMISSIONER
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
�G'iJ/�'�U���01� Tjafyrry✓
(name of facility)
(address
o'f`raacility) -
signature of permit applicant
date
IcbrisaiCdx
�4."' �t t�sachu�clts•-Dtp:rrfritcdt nl !'ublic,Sa ct ?
c Bbard of 6pildim it atiiin+ and SL•rhd a dti-.
Construction SuF;rvisor Specialty License ,
f.. CS s
_.License: L 100451
s s
"Restricted to:. RF,WS
s
KEVIN KEANE A
n 14 FREEDOM ROAD ,
WOBURN, MA 01801 "7' Xv
expiration: 8/12/2012
r'nnad..ai'm r TrJh�100451 a
. •.. •. ✓� '(OOmLhW�NOCA�IR Oy✓ [Ipo(O f
W— J.
Office of Consumer Affairs&Bdsmess RegulatiopHOME IMPROVEMENT CONTRACTOR- Registration �-101742 Type:
Expiration 6i2912014 .. DBA
K-M-K ROOFINGI'�iF �R. >
1 I � � - i� _
i Kevin KeaneRz
I 1d FroMdn Rd
Page 1 of l
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Citizens Bank
511536195
.... r -June 25.-2012
PAY ..�. - # 3;1-60 - 00 p1f .DOLLARS-
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Posting Date 2012 Jun 26
Posting Seq No 94557784
Account Number 20752164
Check Number 511536195
Amount $100.00 e
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Page No. of Pages
Efq,�ACI `/E Ili K.M.K. ROOFING �
Licensed & Fully Insured
MA HIC #101742 MA Lie. #100451
14 Freedom Road•Woburn, MA 01801
(781) 254-3557
PROPOSAL SUBMITTED TO t' PHONE DATE
STREET JOB NAME
e) A— SE,
CITY.STATE and 21P OOE JOB LOCATION
/ 1�
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
We Propose-hereby to furnish material and labor— complete in accordance with above specifications, for the sum of:
dollars is )
Payment to be made as follows'. 9
Alf material is guaranteed to be as specified. All work to be completed in a workmarikke -
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 seikes. 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 will P days.
Acceptance of Proposal —The above prices.sperifications r�
and conditions are satisfactory and are hereby accepted.YOU are authorized to do the Signatur /
work as specified.Payment,/bbe/rrde as outlined above.
Date of Acceptance:Sl{�C�/�� Signature