Loading...
225 DERBY STREET - BUILDING JACKET i �a���`�y S���e� Certificate No: 569-06 Building Permit No.: 569-06 Commonwealth of`Massachusetts City of Salem Building Electrical Mechanical Permits This is to Certify that the RESIDENCE located at Dwelling Type 0225 DERBY STREET UHB in the CITY OF SALEM ----------------------------------------------------------------------------- -------------------------------------------------------------------- Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY OCCUPANCY PERMIT FOR UNTT#607 This permit is granted in conformity with the Statutes and ordinances relating thereto,and expires unless sooner suspended revoked. Expiration Date Issued On:Wed Oct 24,2007 -------- -- -- ----- - GeoTMS®2007 Des Lauriers Municipal Solutions,Inc. ---a^--'----------------------------------------------------------------------- 0225 DERBY STREET UHB 569-06 GIs#: _11207 COMMONWEALTH OF MASSACHUSETTS Map: 34 Block: CITY OF SALEM Lot 0446-804 Category:- _ 102 New Attached Co Permit# -569-06-- - BUILDING PERMIT - - - Project# IJS-2006-001160 Est. Cos[ $40,000.00 Fee Charged: $0.00 Balance Due:— $.00 _ PERMISSION IS HEREBY GRANTED TO: Const. Class: jContractor: License: Expires Use_Group _ _ i Village Construction STATE-054710 Lot Size(sq. fr.):I — downer: PICKERING WHARF REALTY TRUST Zoning: IBS B5 - Units Gained: Applicant: Village Construction Units Lost: - _]AT: 0225 DERBY STREET UHB Dig Safe#: ISSUED ON. 06-Jan-2006 AMENDED ON: EXPIRES ON. 06-Jul-2006 TO PERFORM THE FOLLOWING WORK. 569-06 SUB-PERMIT FOR UNIT#607-06(FROM PERMIT#603-2001) JB POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: Underground:--/- + --Uaderg:ecnd:-_.—/_/ _Excavation:_ Service: ///^ Meter: / i / - Footings: Rough: 1' Rough: (/ Rough: t/ Foundation: Final: Final: Final: Rough Frame: Fireplace/Chimney: D.P.W. Fire Health Insulation Meter: Oil: a/l/ 1O/Z31� Fi 1 House# Smoke: 1 6e-1 Water: Alarm: /V-.4/ &/,gv Sewer: Sprinklers: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLAT OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Chec o: Amount: BUILDING REC-2006-001655 6 Jan`-06 { - X $000 Is ERTIFICATE OF OCCUPANCY upon cointle' Gr II = y is G Call sued. Permit d: 745-`9595 Ext. 385 City of Salem Building Dept. GeoTMS®2007 Des Lauriers Municipal Solutions,Inc. �V September 30, 2004 Thomas St. Pierre, Salem Building Inspector Salem Building Department 120 Washington Street Salem, Massachusetts 01970 Re: Sale Waterfront Hotel & Suites Project (04-022) Derby Street& Congress Street, Salem, Massachusetts Mr. St. Pierre, Based on site visits through 9/30/04, the Pickering Wharf Hotel and Suites project, Derby & Congress Streets, Salem, MA has been reviewed, and to the best of my knowledge and ability, the project is proceeding according to the drawings prepared by Group One Inc. (dated 7/14/03 and revised through 1/26/04) and clarification drawings prepared by H.H. Morant& Co., Inc. (various dates). The project appears to comply with applicable provisions of the Massachusetts State Building Code & ADA. Further, to the best of my knowledge and ability, the lobby, public areas (i.e. lavatories, management offices, egress stairs/elevators) and hotel floors 2 through 4 at the Salem Waterfront Hotel and Suites are substantially complete, and ready for temporary occupancy. If you have any questions regarding this project, please call my office. Sincere] yours, ��, •urs. s St W. ' ermore ,, No,sM A F Pr den ) g SALEM, MASS. SWL/hotelfrltrl l 11►OF 11 FIF-1 K. K. Morant 0 Co., Inc. P.O. Box 4485 Salcm, MawachuwU8 01970 978.744.5354 Fax 978.740.9161 Email: AaMhmoranLcom Certificate No: 603-2001 Building Permit No.: 603-2001 Commonwealth of Massachusetts City of Salem Building Electrical Mechanical Permits This is to Certify that the HOTEL located at -------------------------------------------------- Dwelling Type - 0225 DERBY STREET UHB in the CITY OF SALEM - --------- - - - -- ---------------- --- - Address - Town/City Name IS HEREBY GRANTED A TEMPORARY CERTIFICATE OF OCCUPANCY CONSTRUCT HOTEL 225 DERBY STREET This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires Saturday Oct 30, 2004 unless sooner suspended or revoked. Expiration Date w , Issued On: Thu Sep 30,2004 /``ts? ---„1- -,- - ---- - --------- - ------------------------------------------- GeoTMS®2004 Des Lauders Municipal Solutions,Inc. ---------------------------------------------------------------------------- 0225 DERBY STREET UI-IB 603-2001 COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM ' �tlgt�tg`m' tris x BUILDING PERMIT 4. s¢ t�t in 0(1 11022 ,; t CPst 4r 06 PERMISSION IS HEREBY GRANTED TO: Coals Class` ' Contractor: License: Village Construction General Contractor-Salem#1571 tStzeZs4`t 859 s k orf Owner: PICKERING WHARF REALTY TRUST , 1•.Init&s $e(lt `srvx .\, x ter-4� Apptieant: Village Construction ne AT: 0225 DERBY STREET UHB $ri:`e2�r'S't"'r r •z l .:5n�\.,.,,s,:.�.,h�:�`•f� � ' ISSUED ON: 18-Ian-2ooi EXPIRES ON: 18-Jan-2002 { TO PERFORM THE FOLLOWING WORK: j Construct Hotel per plans submitted.P.S. . 6 month extension 7/18/01-1/18/02 P.S: POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. inspector or Buildings Underground: Service: Meter: Footings: Rough:tC.t - (�` ��',�y� Rough. House#. .._ _ . .. �11 Foundation: Rough FYame: FinalY�jm2 '�'/ 3u Final. �✓L Z ' . . . - _ / /' FSreplace/chi—ey: Insulation: Gas Fire Depa�r°tment, Board of Health Fmal. 9 � ! Rough: �/�`'/�� G✓ T reasury: Final: Smoke: Excavation: i THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIO I N ITS RULES AND REGULATIONS. Signature: Bee Type: Receipt No: Date Paid: Check No: Amount: BUILDING REC-2001-001148 21-Aug-00 1069.. $40,005.00 Call for Permit to Accu pY _ GeoTMS®2001 Des Lauriers Municipal Solutiow,Inc. I fi Jg/% aM IT J;,170 If No ly City of Salem Ward �uM.td.'a,rro j e< APPLICATION FOR PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION IMPORTANT-Applicant to complete all items in sections:1, 11, /it, IV,and IV. I. AT ILOCATION) � � 4-7r—:-A26;'r2 . �� - DI°NM STRCT LOCATION 1N01 OF BETWEEN rv+l .f�F"JG.S- �7 '- AND Y5-74E7 -8r BUILDING 'CROW SMEEn ICR09a STREETI LOT SU130M9ION LOT—BLOCK SIZE H. TYPE AND COST OF BUILDING-All applicants complete Parts A -D A. TYPE OF IMPROVEMENT D. PROPOSED USE•FOR"DEMOLITION'USE MOST RECENT USE 1 Naw bukdng Realdandal Non eellannei 2 Addmon la rcsxkmk 1.enter numbed new 12 ❑ oft tan* 16 0 Amlmamerd.reaesborrl nousmg uma added.d any.In part 0.13) 19 ❑ C)uum peer Mgqus ii�� 13 ❑ Two a rtlofa amlN•Ente number 20 ❑ 1rhtlIAOeV 3 Alleratcn ISee 2 aborel C6;C,�1 P( '7'� of urea-_.� — 21 Q Parltig garage a Repaq repaCertMre 14 ❑ TrareEmberna ber o M0181,funds or dorrrhdorY• 22 ❑ Sarvrre sat em repay gaage - ErlMrwmbsr d unsa.-_-�— ' 5 ❑ Wredhng la mul(ilarNy resdeneek enNr number 23 Q timpial,iaOM1lIDoro. of units m balding m Part D. 13) 15 Garage 24 Q Offfoa,bark.prdssawa l 6 Q M.-V(rebraum) 16 a Carpal /7 .,I/��,,,� 25 ❑ Pubec uMV 7 p Founam m only 17 oche•Speedy CDN 00S, 260 SChMA bcta y other aatrmaal B.OWN SHIP 2R tST- � 27 ❑ Sfax nwrdntis 6 Pn lmdividual.wrbbmub.ronaoa >n�Q ,I /�/ 28 ,Q.y TarlMe.Dowers nsaulion.etC.1 PV iJ,0 c A OC—A 29'Yvl Olher-Specify 9 ❑ Pudic(Federal.Slake.w local 9wermrent ~ N`-'1 �Li 1' /aC C.COST Iona cans) Norraeltla"•Descnbe m dead propoew use of buddega,a.9-look Pracessag prate. madhme WM aandry budddg at hoapdaL ebnhemwy school.secontlary sc hoM college. pemdritl sand.parasg garage for demo we store.rental dffce buddag.office oukdbg 10. Cost d imonmment 'Z at ndugraf pars.It use of eaieting bddairg 0 b"M CIO enter ernte�tx9cpow/df/w/e.n be Missabove ecost ftralcetdad CC7��✓� a 1�Z•'lno—, C✓�Q("r��/� , m me aoora cosy �/� o IZ� b. Pemlbdg_ �yty,G'a �L�N7— _ l cf, . corL)Q c s �c�c�L.�� ,Ieeahg,ad Cahauontng '",�'' d. O11Mr telersla.a1e.! 11. TOTAL COST OF IMPROVEMENT t t coo III. SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-L:demolition, complete only Parts J&M.all others-s_k�ip/to IV F- PRINCIPAL TYPE OF FRAME F. PRNCmACTYPE OF HFATWO FUEL G. TYPE SEWAGE DisposAL I. TYPE OF MECHANCAL 30 I] Ms I lwal beaag) 35 ® Gas 40 Pubad or prthrels cornomw WIN viere me 31 ❑ hams 38 Q ON 41 ❑ PrMro laeple arkL eW / 3 SblceaW gash 37 0 Elecvkcty 4a'�Yes/ 45 Q No ������ H. TYPEQF WATER SUPPLY 1 33 Q Reekdretl P.bflaero 36 � Coal Far,J4. wi�6-,-el/apY.harwbn 34 Q Olfter.Sperly 39 Q 011ie.Specdv d2 PIk1ItC or prima comber 46 m.Yoe 47 ❑ No 43 0 PrIII twak,dales) { J.48 Nur,oero M. DEMOLITION OF STRUCTURES: .la NUmDer Ot a10r1aa ._....._..........._................_..............__ ae Tc!w sm,are reef at hour area Has Approval from Historical Commission been received a..hoots oases w earenar cmernnns .............._......_....-............................. - for.any structure over fifty(50)Years? Yes_ No_ 50, To,ef Lana area M.it.....---._..._.__.__...---..-- Dig Safe Number K.NUMBER OF OFF-STREET PARKING SPACES Peet Control: 51. Enabsea............._.-_------.__...__.__..._...__....... HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED? - 52. omaaas...._..._.__.._...-------------- Yes No L RESIDENTIAL BUILDINGS ONLY Water: 53. Endoee0___-- Electric: Gas Full—. Sewer. I 54. Numbef of aaasoaro DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED Partief._... BEFORE A PERMIT CAN BE ISSUED. IV. COMPLETE THE FOLLOWING: Historic District? Yes_ No (If yes,please enclose documentation from Hist Com.) Conservation Area? Yes_ No_ (If yes,please enclose Order of Conditions) Has Fire Prevention approved and stamped plans or applications? Yes_ No_ Is property located in the S.R.A. district? Yes_ No_ Comply with Zoning? Yes_ No_ (If no,enclose Board of Appeal decision) Is lotgrandfathered? Yes_ No_ (If yes,submit documentation/if no,submit Board of Appeal decision) If new construction,has the proper Routing Slip been enclosed? Yes_ No_ Is Architectural Access Board approval required? Yes— No_ (If yes,submit documentation) Massachusetts State Contractor License# �"t �i U Salem License# Home Improvement Contractor# Homeowners Exempt form(if applicable) Yes_ No_ CONSTRUCTION TO BE COMMENCED WITHIN SIX(6)MONTHS OF ISSUANCE OF BUILDING PERMIT ,, ` ,� If an extension is necessary,please submit CONSTRUCTION IS TO BE COMPLETED BY: 1 �jc� `j in writing to the Inspector of Buildings. V. IDENTIFICATION • To be completed by all applicants NArn! Mating address-Number.street coy,anti aura LP Code Tel No. '4'6OJ6ei I eta F Ac_---i-F 5i- of j45_ 7e16;i oamef or 2. l l� 6L2 -VI 6-51— &VOConnow l;�„D. - 7777 3. Q I� 7s� l l� �(6 7�e� ✓� Cr6XQ7574+ Ardallo or , 1 Gb I hereby certify that the proposed w_otkjsauthorized by the owner of record and that I have been authorized by the owner to make this application as his authorizes aaent ana we agfee to ftpform to all aoDlicable laws of this jurisdiction. /'� /� Signature of appli Address (:ppi/a date r DO NOT WRITE BELOW THIS LINE VI. VALIDATION Building FOR DEPARTMENT USE ONLY Permit number Building U58 Gip Permit issued 19_ Fire Grading Building Permit Fee $ U'e Virg Certificate of Occupancy $ O v 1 W Approved Drain Tile $ 71m7 /t/ Plan Review Fee $ 1r TITLE NOTES AND Data• (For department use) XQ 6 m C/ pq/ < PERMIT TO BE MAILED TO: DATE MAILED: Constriction to be started by. Completed by. DERBY STREET 76-12 COMMONWEALTH OF MASSACHUSETTS j CITY OF SALEM 11843' 34 a fj {iy B'° k: u' {„ SIGN PERMIT Lot 0446-804 Permit:.'�'� Category: -SIGN „ ,• _ Permit# 76 1z PERMISSION IS HEREBY GRANTED TO: Project# '.,. JS-2012-000224 , Est. Cost ` -$2,000.00 Contractor: License: Expires Fee Charged:$0 ::a_. ' applic 00 ant Balsnce Due:$.00 °€1 _ Owner: PICKERING WHARF REALTY TRUST,ROCKETT J HILARY TR #of Fixtures Applicant: Salem Waterfront Hotel AT: 225 DERBY STREET UseGroup.P '. 7a,ar'" ConstClass. illlh` y z ISSUED ON. 28-Jul-2011 AMENDED ON: EXPIRES ON: 28-Dec-2011 TO PERFORM THE FOLLOWING WORK SIGN PERMIT AS APPROVED FOR THE REGATTA PUB jbh THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: SIGN REC-2012-000243 28-Jul-I I x $0.00 GeoTMSO 2011 Des Lauriers Municipal Solutions,Inc The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building ,Code 780 CMR SALEM Revised:l iar 2011 s Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Dvo-Ftnnily Dtvellin�' This Section For Official Use Only Building Permit Number: Date Appli d: Building Otlicial(Print Name) Signature SEC ION l:SITE INFORMATION I.I Property A dress: 4 1.2 Assessors Map& Parcel Numbers i 1.1 a Is this an accepted str t?yes_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) 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: Zone: _ Outside Flood Zone? Public❑ Private❑ Check ifyes0 Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: -�a �e caw ��©ear > � s�le�� , o �ezo Name(Print) City,State,ZIP as 5- *De- f , g 7S -740-37SS No.and Street 'f elephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ 1 Existing Building❑ I Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Descri%,onoIProposed Work': 2'1- u 4 D` Ji e r,7!'2C.,(C cQDW� !may J i/CS L L tr SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Nlaterials I. Building $ I. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical g ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ �- 4.hlechmtical (HVAC) S List: (�(� S. :Meclmnical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Antonin: 6. Total Project Cost: $ 41V 0 paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES rcs n Supervisor License(CSL) License Number lispiration Dane er1_ist CSL'f)pe(see below) Type Description U Unrestricted(Buildings t to 35,000 cu. ft.) R Restricted 1&2 Fanul Dwelliny _IP M Masnnr RC Roulin C a v c r i n WS I Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Lmail aJdress D Demolition 5.2 Registered Home Improvement Contractor(HIC) �l ,e ll�S Fob lee.-i IIIC Registration Number lispiration Date I lt�,�T N:)me or I eC liegistrunt Name No. and Street Email address F-L4A9 ,4 �/1� 019GD 978-S�S-5��5 Ci /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 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 4�E VC.Lc.+S F&( to act on my behalf,in all matters relative to work authorized by this building permit application. �544ev-L L J&7ftr(r-o ,+ ka4,e ' :�S/1 Print Owner's Name(Electronic Signature) ate 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 contained in this application is true and accurate t the best of rim knowledge and understanding. 'aC e-44 /r,CG - S Print Owner's or AuthunzeJ Agents Na mn(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 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 yyww.mas,yo}vua Information on the Construction Supervisor License can be found at ww w.mas,_ggv ilk 2. When substantial work is planned,provide the information below: Total Boor area(sq. ft.) (including garage, finished basenment/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathroonms Number ofhalt%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' ehlPC�Ii df'6 a °�� %�� I'he Commonwealth of Massachusetts CITY OF �JI l•' Board of Building Regulations and Standards SAL[ M Massachusetts State Building Code, 780 CMR Rerised.11ur?o/I e„W Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Trvu-Fumib,Dn elling This Section For Officia],Wsc Only Building Permit Number: Date plied: Building Oil-,,, Name)cial(Print Name) Signature / Date / SECTION 1: SITE INFORMATION 1.1 r�operty A es�•• 5 r 1.2 Assessors Map& Pa c ers rlo� I.I a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensio Zoning District Proposed Use Lot Area(sq tl) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (Mj L c.4o.§54) 77 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Public❑ Private❑ Check ifyes0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 7 O 5a, r w4F��rouF f ( f�( ec�t t/12l¢ or9 - N,une(Pant) City,State,ZIP � �S 17a.rlac. 5� . YZ�-7yo - $7fr� No.and Street 'relephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': -)1 o� as`x "' TPt •F Du 1 7 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and \Imerials 1. Building S 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)s multiplier x ?. Plumbing S 2. Other Fees: S 4. \lechanical (HVAC) S List: 5. Mechanical (Fire S 'Total :\II Fees: S Suppression) Check No. _Check Amount: Cash Amount____ 6. Total Project Cost: 3 //`/p ❑Paid in Full ❑Outstanding Balance Due: l 7Construction p SF.C"1•ION 5: CONSTRUCTION SERV ICES peisor License(CSL) ry NToc k icensewnhc Expiration Date '142List CS_ I)pc(+cc heluy) B LL)e Sf No. and Street Type Description Pe A I✓o� 1 �� D)Q (90 U Unrestricted(Buildin�s up to 35,000 Co. It.) Coy/lotto,State,ZIP R Restricted l&?Puntil Dwelling M Mason RC Roolin Covering —" W'S Window and Sidin SF Solid Fuel Burning Appliances I Insulation "fcic hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1114. Company Name or I IIC Registrant Name IIIC Registruion Number Espiratiun Date No.and Street Email address Ci /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 denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... V 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_ ut-VI`(S 1:7�I— �,Q 4- /' � •. tGC\ to act on my behalf,in all matters relative to work authorized by this building permit application. Po-Le 6 Pont Owners Name(Electronic Signature) Q� to SECTION 7b:OWNEW OR AUTHORIZj NT DECLARATION By entering my name below,I hereby attest under the pains and pe perjury that all of the information contained in this application is true and accurate to the best of my e and understanding. ✓t A is �o r e �d / Ketif/ Y? `oe� / / I rent Owner s or,�uthori Zed Agent s Name(F, canonic Signature) Dale NOTES: I. An Owner who obtains a building permit to do his.her own wowner who hires an unregistered contractor (not registered in the Home hnprovement Contractor(HIC) Prill fro(have access to the arbitration program or guaranty Fund under M.G.L.c. 142A. Other importation on the HIC Program can be found at t})��t.,rh,).�..��ry ite❑ Information on the Construction Supervisocan be found at t�X��y_.ni 2. When substantial work is planned, provide the information below: Total fluor area(sq. R.) (including garage, finished basentent'attics,decks or porch) Gross living area(sq. fl.) _ Flabitab1,room count _ \'umberufFireplaees Number of bedrooms Number of bathrooms __ _ _ ---- -------- Number of half li, 1)pe of heating system _ --__-- Number of decks, porches--------------- 1'y pe of cooling sy slant E ----------------- nc losed _ Open i 'Total Project Square Footage-may be SuhSlinued for"Total Project Cost" -_ . -- ---- I'he C'onunoil weal th of Massachusetts — Board of Building Regulations and Standards CITY OF MaSSachuscRs State Building Code, 780 CNIR SALLM Building Permit Application To Construct. Repair, Renovate Or De a One-or Tlrn-Fonti(n Duelling This Section For Official se Building Permit Number: Date - ppli JSy Ifuilding Official(Print Name) Signatu Pale SECTION I:SITE INFORNIATIO 1.1 Pr o)ertV r�e ° 1.2,assessors Nlap& Parcel Numbers I.la Is thisan accepted street?yes_ no Map Number Parcel Numher 1.3 Zoning Information: 1.4 Property Dimensions: Coning District Proposed U c Lot Area(sq il) Fmnlagc Ill) 1.3 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Pm ate❑ Zone: _ Outside Flood Zone? Munici al❑ On site disposal Check if ts❑ P posal s stem ❑ SECTION 2: PROPERTY OWNERSHIP' 2 1 Owner'of Record: dame(Print) city.State.LIP 2 2 �crb r Ck 979 7YJ97&9- Nu.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description f Proposed Work: t o SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and .Materials) Ofllcial Use Only I. Building $ I. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Custr(Item 6)x multiplier _x t. Plumbing S ,_ Other Fees: S ------- 4. .Mechanical III\':\CI $ List:_ 5. .Mechanical (Fire $ .-- _-- -------- - Su vession) rand .\II Fees: Cheek No. Check:\nunrnt: Cash AITIOUnt:o. Total Project Cast: $ — ------ - /(/� " 0 Paid in Full ❑pulsumding BaLotce Due: f SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(C'SL) License Number I\piralion Date N;nne IT,-CS1. I)older List CSI. I,)PC(see below) I)PC Description No, and Street U l4vestricted I Buildings t10 to i$,UIIO nl. 111 _ _ _______,_,_ R Restricted IS2 Tamil MwIlin Cil_ci fowl,Stine.LIP NI Masonry RC Rooting C'owrin INS Window and Siding SF Solid Fuel Burning Appliances I Insulation 'I'cic bona Iinlail address U I Demolition 5.2 Registered Home Improvement Contractor(HIC) IIIC Registration Nunlher INpiralion Date - I IIC Compan) Name or I IIC Registrant Nanle No. ;old Street Email address _ City/Town. State,ZIP T¢Ic hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 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 Nalne(Electronic Signature) Date SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION By entering illy 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. Ir4dt Owner's or:\uthon red A*nt's Nome(Flectrunic Signature) IDitti NOTES: I. An Owner whu obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor (not registered in the Hume Improvement Contractor(HIC) Program).will uo 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 m.n. „s -,.i Information on the Construction Supervisor License can be found at a\%,k nm,+ �� ,N ,lit, ? When substantial work is planned,pro%ide the information below: Total Iloor area(sq. ft.) _ i including garage, lmislwd basement attics,decks or porch) Gross living area(sq. 11.1 __- Habitable room count N'umberoffreplaces_._. . ._ _. _ --- Number of bedrooms - Numberofbathrooms .. . __- Numberofhall'hadu I\pe of heaving system Number ol'decks, porches I\Ile ol'cooltng S\Stem _ .. ._ - l?nclosed _ - . _ -_Open 1. 4fatal Project Square Footage'map be substituted lift"I'olal Project Cost' �\ The Commonwealth of Massachusetts ' } Board of Building Regulations and Standards CITY {t`y ) Massachusetts Slate BuilJir16 CoJr, 780 CMR, 7111 OFSALEM edition RevisedJunnury Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 11H6Y One-or Ttvo-Fulrtily Dwelling / 7/j y j(✓ This Section For ITicial Us Onl (✓ rIJZoolng g Permit umber. E 1/�, D App 'ed: re: �0�0/� Building Commtssi r/ ns to of Buildings liate SECTION I: S TE INFORMATION a Address: _r 1.2 Assessors Ma & Parcel Numbers l)es- ST, p this an accepted street?yes ono Map Number Parcel Number Information: 1.4 Property Dimensions: istrict Proposed Use Lot Area(sq 11) Frontage(11) I.S Building Setbacks(R) Front Yard Side Yards Rear Yard Reyuired Provided Required Provided Required Provide) 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if es0 Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 oyrner'of Record: Sec to:� [, fie,,. ,1 1 eQ a¢ o-zc7 -- 7Jt t� 5�. Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (cheek all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alleration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work: Se u� 0,XA0, !=4 i— l�/�yl/D /S�e�/�a�o o SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: 0111c1a1 Use Only Labor and Materials I. Building S 1. Building Permit Fee:S Indicate how fee is determined: O Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 1. Plumbing S L2. 01her S 4. Mechanical (IIVAC) S 5. Mechanical (Fire SSu «ssion S Check Amount: Cash Amount: 6. Total Project Cost: S �lf 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) license Number Expiration lyale Name ol'C'SI.• I lolder List CSL'type(sec below) Ts Pe I Descritsion Address U I (Inresuicted(up W 35,000 Cu.Ft. R I Restricted 1&2 Family Dwelling Signature M Masonry Only RC Residential Rwring Covering telcphone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D I Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature Tclephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.6 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 Affidavit Attached? Yes .......... No...........O 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Si Lure of Owner Date I�, ) SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION ,S I. G yL'ynl- 'Fo(— R'e t,,4-- ,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 behalf. Prin- � /W-/ �F t/ Q/ /e) r Signature of Owner or Authorized Agent Date (Sianed under the pains and penalties of 'u 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 WJ have access to the arbitration program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 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 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 J. "Total Project Square Footage"maybe substituted for"Total Project Cost" The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SAMar Revised Mar 2011 �� Building Permit Application To Construct,Repair Renovate Or Demolish a `/h '—Y One or Two Family Dwelling x *.� Bu 1mgFermrtl umber 3 Date* PPhedx a r k { Building Offic al(Punt Named R C z ,v Signature x s k z Date 1.1 Property Address: 1.2 Assessors Map &Parcel Numbers L 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 ft) 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: Zone: _ Outside Flood Zone? Public El Private❑ Check if yes❑ Municipal ElOn site disposal system ❑ ti 4r Ya A +. x 3 ".c,. k c '1"''r 5� § N�k, 5°y,v?" .._ "#. i.., § •;� ` 2.1 Ownerr of Record: --1 �� lZ�c%F X Name(Print)` City,State,ZIP / 1 12 3 /14302A/ S�. D ill er 918-37G- l To EALE1C'A-1-7 CO-N No. and Street Telephone Email Address x _ x SECTION 3 DE$nCRIZ'TIQN OF PROPOSED OR (check that apply] New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work2:07 O X 3 O i'l—Ap4TV 7,—A,,Jc k ,SECT 4 ESTI IA�ED.GONSTItTJC TIOA COSfS Estimated COSTS: OR wg§�r qx Item Labor and Materials h �� OlfisIP1e �illx k r T 3 ar Fe '1. Building e $ ,Iiceowe'dseennned :< 4 au ' 2.Electrical. $ ❑Sanatd�Czty(Tow vlppJcaho�n l eel a ® IbYaL�Prolect Cost (tam G)x must-m ies> r" ."h rvY�1. W S Y 3. Plumbin $ Qd? M U,�` g 2 er s:xl$ *: s � f / 4. Mechanical (HVAC) $ A-1ttk� � �- xa �' 5. Mechanical (Fire Suppression) T ova]All Fees $ � r a z x CheClcNa O eckAmpunt�y CashAmo0- 6. Total Project Cost: $ �,p p�(d in Fu11 �, �Outstandtng Balanoe,Dfie�t v E SECTION 5 CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) -?4 �L C License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street ,,Type „ .y - Descuphon r �Uy /11,Q2 U Unrestricted(Buildings up to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling City/Town, State,ZIP M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 916 7??-2oSD TD Lq r_E2 6,410 A Ce w I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) H HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date No. and Street Email address City/Town, State, ZIP Telephone ' SECTION 6. WORKERS'COMPENSATION INSURANCE AFFH)AVIT(VLG.L c 152. § 256(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-BUILDINGPERMIT t, 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) Date _,SECTION'7 b:,OW-N)RR,ORAVTffOR1ZEDWGENT-,DECLARAT By entering my naive 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. ACe4 /el -3- l2 rint Owner's or Authorized Agen ' ame(Electronic Signature) Date :NOTES irt= 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.mass.eov/oca Information on the Construction Supervisor License can be found at wwcv.mass.tov;'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" M-WM. • as. tc c at t at � , t t it at at a •• y 7 sIL a as as a ac a sa as sa a as as as a s LLL���IIIJJJ J C erft icacte of fflaMt eli t ce F 6 A S 6 U ISSUED BY..: ... . .. ... . . a N/s L WARNER SHELTER SYSTEMS LIMITED Calgary Alberta,Canada rruNRO 1.800.661.6155 This Is to certify that the fabrics used in the manufacture of all WSSL tent covers and wells for. x Company TOTAL ENTERTAINMENT u a city MA Province/State usa �_ • R are rm•retardant having been lasted and found to pass the reomments of. California Fire Marshal National Fire Prevention Act, NFPA-701 Underwriters Laboratories Canada,CANNLC•S10g-M for the use in tenl tops and walls, Each WSSL tent lop or wall has a permanently affixed label stating that the fabric used has passed the aforementioned tests. Flame relardancy treatment is effective for life of material and renewal cedipaallon is not necessary. W t31� PIMMW r• a 't - The Commonwealth of Massachusetts . 1 Board of Building Regulations and Standards PCN2 Code 780 CMR, 7"' edition MUNI USE' LI'll' Massachusetts State Building d ), USF Building permit p - rmit Application To Construct, Repair. Renovate Or Demolish Ole Ret ised Jamim i This Section For Official Use Only C/� Building Permit Number Date Applied: Signature: —2I- w Building onunissioner/ Inspector of Bui Wings Date SECTION 1: SITE INFORMATION 1.1 Pro ert Address: 1.2 Assessors Map & Parcel Numbers Pew ` 1.la Is this an accepted street? yes_ m✓ �_ Map Number Parcel Number 1.3 tning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot A�fit) Frontage(li) 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: Zone: _ Outside Flood Zone'? Public z Private© Check if yes❑ Municipal M,1 n site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Re or d: 2 1 S�—t � /— �z��� a f t}�'��t Name (Print) Address for Service: 9 2 y - 7'-/O—i�9yo Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Altetation(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': .-c ��-- i SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official U On y (Labor and Materials) �- 1. Building $ �� OL)o 1. Building Permit Fee: $ n irate how fee is determined: Standard City/Town App ication Fee 2. Electrical $ 1 QUJ TYTotal Project Costa (Item 6) x multiplier x 3. Plumbing $ OC) 2. Other Fees: $ 4. Mechanical (HVAC) $ J List: 5. Mechanical (Fire $ Suppression) Total All Fe . S �� Check N Check Amount: a.�h , nxnmt o. : 6. Total Project Cost: $ OO D 19tRA id in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) 54I�i 6 i^�/lael Rixet4 �J l ll /� (' License Number Expiration Dale ' NWt Cp H�`Ur a �Y . List CSL Type (see below) Type Description Address U Unrestricted (up to 35.000 Cu. Ft.) R Restricted 1&2 Family Dwelling W6 M Residential Only e RC Residential Roofing Covcnne Telephone \VS Residential-NVindow and Siding, SF Residential Solid Fuel 13ur11111121 A 7 tlianec nSI;Iholl Ull D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature 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 n) 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 to act on my behalf, in all mantels relative to work authorized by this building permit application. Signature of Owner Date S TI N 7b: O ERt OR AUTHORIZED AGENT DECLARATION , 1, a l x.A, , as Owner or Authorized Agent hereby declare that the statements and information on[ e foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name I Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury) 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. ?. When substantial work is planned, provide the information below: Total floors 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 j 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" 3/ -674/ The Commonwealth of Massachusetts ° Board of Building Regulations and Standards Town of Massachusetts State Building Code, 780 CMR, 71"edition Wilbraham Building Dept Building Permit Applicati o onstruct, epair, Renovate Or Demolish a 413-596-2800 ne- or t o-Family Dwelling - Ext 118 This tion For Pfficial Use Only Building Permit 14111 ber: I Pate Applied: //,^A/{ ,�,�i Signature: I • 5'a OS Buildiqk Cronrunt sioner/Insp c o uil ings Date SECTI :SITE INFORMATION Property Address: 1.2 Assessors Map At Parcel Numbers FZS 7€464 SCtLECV' I a is this ar,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(fl) 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?Check if yes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' Owner'of Record: 11 SHIM WAC�t�2o►3T twT ZZS O�¢t3i I S'C2 �� Name(Print) Address for Service: I Signature (T #` — Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work 2: J.�A-,W 4 o Y g 0 �Fi­^yA.i& TbN`1r i ti FC AX- �4N! fat�t<fKn�T ori�l� . SeJai r.tx S '[ top N to �t n SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical g ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES e 5.1 Licensed Construction Supervisor(CSL) $45>k License Number Expiration Date Na of C —Ind�" T List CSL Type(see below) Addres ^ � Type Description s V U Unrestricted(Lip to 35,000 Co. Ft.) R Restricted 1&2 Family Dwelling Signature C-,c M Mason Only 1S S:SSSa3S- RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name - Registration Number Address Expiration Dale - Sig nature Telephone SECTION 6: WORKERS'CODIPENSATION 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 denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No......... ❑ OSECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize _ _ __ _to act on my behalf, in all matters relative to work authotizec h this but krirg pc^.-tt appiicli;on. Si nature of Owner - Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION - 1 ,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 behalf. Print Name Signature of Owner or Authorized Agent Date Si ne_d under the aims and penalties ofperjury) 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned,provide the information below: Total Floors area(Sq. FL) (including garage, finished basemenUattics,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"maybe substituted for"Total Project Cost"