12 WOODSIDE - BUILDING INSPECTION r
'I The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 780 CMR SALEM
Revised dlnr_Ol l
%ice*s
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: - D e Applied:
Building Olticial(Print Name) Signature Date
SECTION 1: SITE INFORMAT
1.1 Property Address• 1.2 Assessors ap& Parcel Numbers
i2-, `Moac�' fc e---
I.la 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 R) Frontage(It)
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 OWNERSHIP' _
2 Owner'of Record: r4G v 5
U fyl W1Cs(�? L2v11 1L1
Name(Print) City,State,ZIP
12 Lo00c(S,dG_
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building X I Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Propose Work'-: A ILIh ' 1�C� G
h o n c K 4
�; TS on��on� otC�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S r�9 �, OO I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical ❑Total Project Costa(Item 6)x multiplier x
3. Plunmbing 2. Other Fees: S
4. `lechanical (HVAC) S List:
���
5. Mechanical (Fire $
Suppression) Total All Fees: S
q Check No._Check Amount: Cash Amount:
6. Total Project Cost: $ 59 3 1 ❑Paid in Full 0 Outstanding Balance Due:
r t
SECTION 5: CONSTRUCTION SERVICES
7CS
tion Supervisor License(CSL)
►oiR2 t f 2 i oi3
C { License Number Ex iration bate
folder �,ListCSLrype(secbelow)Type Description
�/ 'hl U unrestricted(Buildings no to 35,000 cu. 11.)
R Restricted I&217aniil Daellin
C'itylfown,Slat ,ZIP M Mason
ry
RC Roofing Coverin
q WS Window and Siding
9yy Q 17z / 1p. SF Solid Fuel Burning Appliances
�D CoyPCUf/Kyh 1 11 V C /I 1 Insulation
Telephone Enmil address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) '4 OI g j 7 ZO
Ro\� e tJ{d l9 h 111C Registration Nan nOcr Expiration Date
INC CompOany Name or I�)_IIC Registrant Name
U �jVe W • '
and Street �'o)/ECUI'rAn lh l7 ����
B ,e v I` h'1 P, ZD/C{ /J! 9 9 /'-'� Email address
Ci /Town, St Ste,ZIP Telc hone
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
FITt will result in the denial of the Issuance of the building permit.
avit Attached? Yes .......... ❑ No..........
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
f the subject property, hereby authorize
behalf,in all matters relative to work authorized by this building permit application.
Name(Electronic Signature) Date
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my naive below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true an ac urate the est f my knowledge and understanding.
Print Owner's or Authorized Agent's Name(F ctronic Signature) pale
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
a sav_m;i,.cor_'oca Information on the Construction Supervisor License can be found at www.m;ns.gov_dL
?. 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 he substituted for"Total Project Cost"
CITY OF S.UF.ANt, LNL- SSACHUSETI'S
SUMOLNG DEPARTMt&NT
120 WASHLNGTON STREET, Yo FtOOR
Imo. (978) 745-959S
PAX(978) 740.9846
Ki\®ERIEY DRLSCOLL
MAYOR THo-%w ST.PmRas
DIRECTOR OP Pmic PROPERTY/81:ILDNG COMMISSIONER
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 1 t 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p 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:
SDI �
(name of hauler)
The debris will be disposed of in
6!5:) � cv
(name of facility)
(address of facility)
�/ gnature of permit applicant
2 a �J
date
dctfnatl/Jw
�+ CITY OF SALEM
PUBLIC '
�.� C 1 RUPRERTY
DEPARTMENT
.�w:: Nf 1 Y:,MIN t91
i!C\Vnstn.\ti It^j int I.NA,Msw.u.ia NO I Iv J177�-
I'rd:77}:IS•ri�l3 a 1't%. v79.7412•1346
Workers' Compensation Insureence :%tQdavit: guilders/Contractors/llectrlcians/Plumbers
e elicant Inftmnrilon
�� Pleas Print Le 'hl
V;IIM l ,/lluv�N,•�it)raanvnioNlnJlvuluull: 1\a y
Address: GovP A f) 47
Ci1y,5rara%ip �e t �("1y m I'huneN: �7� g� f 2 �
t
.\re)uu an employer'!Check the approprlale boa:
I I.0 1 ;uee a employer with 4. f>M o/pneJeet(rcyulred);
❑ 1 am a gmcraljm�
actor and 1
Lanyscif.
yccx(lull and/or purt•Iintej.• how hired theuntracturs rt'���New construction
Sole propricim or partner• listed on thea sheet. : S�t� RetnodeRn`ml leave no etnpluyces These subcons havo tl. llemolirion
g tier me in any capacity, workers'campronee.orkers'cutup, iusutnnce 3. ❑ We ara a rnl9• ❑DuiWing uJdaiund. po and its) atylccn have osd their I Q.0 Electrical repairs or additionshmaeuwner doing all work right ofcacmptr hiUL 11.0 Plumbing repair%or additions. IKo ernrkcn'comp, c. !32,3 l(4),anhove nn 12.0reprrsce required.) r employccN. IKors'nrl.J 13 0 Other
ihw chcka lla wt muo a1w fill uw life WC114n t%I%w awwina nNir wwetui cuntit"W vn ydiey utfinmutiwa
'I Ivmwewrrra l 0 ru4,nit cult amaavit indlea,ine IA,ry are auine al work and then Aae wtuG euurlwtors mwl.ulvnp a""rindivie indi,,aina%net•
•r•,nlrxu,n IAM aM<k tAif Amt mew auxAd.w a,lauiun.l .Anwina Iha nail%ornr rulk eGWXW S and thew%ureters'rnmo pdecy mnennail.
/fun art cutployer that If pruvidina rvurkerr'rurnpeamdon himmanee/br ray ernpleyees. Below/s the pu/lay and/ub sift
in/urururG.n�
In.vurancc Cenipany Vmne:
Policy a or Sulf-ins. Lic.n:
•— Expiration Date:
Job Site .Address;
City,Stateizip:
Attach is copy.of lho workers'cumpen.fatlon policy declaration page(showing the policy nunibur and expiration date).
Failure w vccuro coverage as required under Secliun_ear% ui'%IGL c. 132 can lead to the imposition ofcrim a
inal pe nallies o/
tine uP er SI.Sn0.011 andiur una-year imprixm m .f w
unc ,aell as civil lxnuluwt in the 1•urin of o STOP WORDE
o till In S230.00 a Jay.Igaillm lift violator. llc advi.4cd thus a R arnl a tint
copy ufthu K ORstutcmcm may be IurwurJcJ Iu the UlDE el'
In%"N11"umrns wit t1le UL\ for nesurn:cc anen�c scrilivanmt.
/du hereby certify teal paint rJ prner c ufptr/ury that the in urenuflan l provided above is true toad corrvet
ii�: hind _ /
ri„ : •, R l92 ) O3 20 J
use only. Ao not'write in thtr area, to be ruwpleted by city up town a//1riuL
i
)own:WhurityIF
�1111ca1d1 1 Iludding IlcparnneClerk 1. L•'Icctriral lutpertur i. Plumbing Impeetar'tnuu: I
r
Information and Instructions
on in he service of another antler:Illy cuntmct of hire.
�1.1ss.tchuseus Ucneral laws chaplet I J2 IegWfeY all C1111)la)ers to provide worker! compensdtum tar their eolp oyees.
1'ursu.utl to this.mature, do rmplgree is detitted us"...every iK' .rs
%press or implied, oral or written." or any two or more
�n crepluper 1s detineJ as"an individual,purtnenhip,assoeianoa.corporation or abet legal cnhry,
amerse, a association or other legaa entity,ampluYind employees. Itnwevcr the
a the tarcgomg a lincild m a joint enterprise, and including the legal represauatives of a deceased empluYcf-Of the
tup,
,ecetver or trustee ut.1n individual. p
t of ft
owner of a dwelling house having not more sthan ons tothree
maintenance-�nhuu�oneot repair work oncsuch dwelling house
dwelling house of another who employs pe
all not because of such employment be deemed to be an employer
or on the grounds or building appurtenant thereto sh .'
�IGL chapter 152. 425C(6) also states thut''every state or local licensing
bu agency the withhold the Issuance or
renewal of a license or permit to operate a business or to Construct buildings in the Commoawaverage re for any
antal with the Insurance c
applicant "Ile has not PrntI S o d' acceptable(7) tates-'Neither he once of unonw.alth ur any of its political gtubtlivisrons•shall
t,dditionally, SILL chapter I S_, a_ ( 1
outer into any contract tar the perfomwnce of public work until acceptable evidence of connpliarlca with the insurance
requirements of this chuper have been presented to he contracting authority."
Applicants
es and bona numbers)along with their cartificutOW of
Ploasa fill out the workers' compensation aPAdavit completely,by checking the boxes that apply to your situation and,i
necessary, supply sub-contractors)n unep),address( )' P (LLP)with no amployl as other than he
insurance. Limited Liability Companies(LLC ON workers' tom pensatioLimited Liability e imurOn'rships(If an LLC or LLP does have
members or partners, are not required to carry
en mbereo,u policy is required- Be advised that this dlIldavit Ivey be submitted to the Deportment of Industrial
Ile be sure
he rAccidents
timed to the city or townithat hecappl cation rot he permit orolicensenis being raquestedd data the vnot rife Department should
Industrial Accidents. Should you have any questions regarding the law ur if you are required to obtain u workers'
compensation policy,pica"call the Department at the number listed below. Self-insure
companies should enter their
self-insurance license number on the a ro riuta line.
city ar Town offlclsU tinted complete and pi applicant.
r!ctha affidavit�or you to affidavit
ll autsin ha event the O Tea ot�lnvestigrt investigations hd1)to Cunt et you regarding the provided it Vice tapphu�tom
t
I'I:ase be sure to till in he purmit/license number which will be used as n referencenly s number. In addition, is applicant
ur
that must submit multiple penniUlicmise applications in any given year,need only submit ono affidavit indicating curter
the cis or town may be provided to the
policy information of necessary)and under"Job Site Address'the applicant should write"I'll locutions in—(city
town). \copy of the uTduvit that has been officially lumped or marked by Y
applicant as proof that a valid affidavit is on rile to fLturo Permitsnii not related to any bunses. A now isinesslor comeuterc I venture
year. Where a hwna owner or citizen is obtaining a license or p
d dug License a permit to burn leaves cte.)said persun is NOT required ro complete his affidavit.
I he 1 NLce ul Investigations wool d like to think you in advance for your cooperation and should you hate any quesuous,
please du nut hesitate to give m a call.
the ucparunent's address. telephone aThnd Commonwealth of Massachusetts
Department of Industrial Accidents
011lesi of Invesdgadons
600 Washington Street
Boston, MA 02111
'ref. lit 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727.7749
t:. . d 3.2o Ins www.mass.gov/dins
+_.. Nassachu.ctt.- Dcpartntcnt uY'Public S:dch
Board ot,Boildin� Rrulations and Standactls_
Construction Supervisor License
License: CS 101924
- Restricted to: 00
ROY CURRAN III
8 GOVE AVE
BEVERLY, MA 01915
Expiration: 2116120;13_,�
Tr#: 101924 -
07e TOamrmoou0ea�.l�c oy✓�.a4aac�%uoe •.
Office of Consumer Affein&Business Reguta8ao
- HOME IMPROVEMENT CONTRACTOR
Registration 168018 Typs:
Expiration: 12(712012 DBA
i r _
UILDING&REMO.OELINO,;;y
ROY CURRAN III
8 GOVE AVE r� s�i� �•
BEVERLV MA 01915<' Underseerehry ' 1