12 BARSTOW ST - BPA-16-1025 REMODEL 2ND FL BATH �,,$2 K Ojz,
The Commonwealth of Massachusetts
n Board of Building Regulations and Standards SALEM
U / Massachusetts State Building Code, 780 CMR Z01b SEP —CJRe1Aed&tdZeP11
N Building Permit Application To Construct, Repair, Renovate Or Demolish a
DOne-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
.S
Building Official(Print Name) Signature Date
SECTION l:SITE INFORMATION
Property Address: :-E 1.2 Assessors Map&Parcel Numbers
1.
la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided RequiredProvided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public Private❑ _ Check if yes❑ Municipal W10.site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[ -
2.1 Owner o Record: \ (�
RorCY Z><Luec maw QeAc � , O._) \cj(o C')
Name(Pr�— City,Stall,ZIP
Q €mec-SaIrs SA-3,;Is I$? SF-C� 0. Coat
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building, Owner-Occupied ❑ 1 Repairs(s))d I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units- Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labo and Materials
1.Building $ Oil 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
750 ,0c73 ❑Total Project Cos[ (Item 6)x multiplier x
3.Plumbing $ �Q�.GO 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $ .Y..
Su ression
�7 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �/a5�.� Cl Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS_ Io4i Sag IL--&--L7
e� License Number Expiration Date
Name of CSL Holder
bn-Y List CSL Type(see below)
No.and Street 1 Type Description
L e011` ky\5 V-ex— mic., dNyS3 U Unrestricted 2 Family
D el ing cu.R.)
R Restricted 1&2 Famil Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
9c p-�-� �? SF Solid Fuel Burning Appliances
70_oJ.>2t� -vk„ctC'1V�CyyN` Couv.�Co.S N 1 Insulation
Telephone Email�Ndress D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
Ke V\ 5 mo,AA l 7o25,6 �Ex a i
`2 HIC Registration Number Expirationn Date
13�oAnpa6 N Y e or H(C Registrant Name
it
Np�and Street / E it address
U-0M\o1S-er N)N ,(1)LL;Z,;--2,
Cit /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 ..........Yn No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR
BUILDING PERMIT
1 11
1,as Owner of the subject property, hereby authorizeJ V�'QVk� k
to act on my behalf, in all matters relative to work authorized by this building permit application.
, oy `;�--%� 1towy\ l
Print O 's Name(Electronic Signature) Date
.. 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
contay'ed in this application is true and accurate to the best of my knowledge and understanding.
&e vi/-\ T f PaI/�- 9-S -/6
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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(HIQ 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 www.mass. oe v/dos
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"
: Massachusetts Department of Public Safety
IMP Board of Building Regulations and Standards
License: CS-104529
Construction Supervisor
�r:rix n
KEVIN J MAILLETS
339 DAY STREET
LEOMINSTER MA 0�
x
'Y. \�
.,1'l5H`A
j r, ZU;,. Expiration:
j Commissioner 1110612017
,y. �>��anvmar>tiaea�z a��anac�u�°eltn
JN Office of Consumer Affairs&Business Regulalioo-
HOME IMP.ROVEMENTCONTRACTOR
Type:
Registration _170788 Irttlividual
Expiration—: -12/2112017
KEVIN J.MAILLET .h S
KEVIN MAILLET
339 DAY ST
LEOMINSTER MA 01453 Uudersec%etary
a
CITY OF siu Ems I XSSACHL'SETTS
BUILDING DEP. -r
130 WASHINGTON STREET, r FLOOR
TEL (978) 745-9595
FA.Y(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR TriobtAS ST.PiERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information [ Please Print Leeibiv
Marne(BusimnsiOrganizatiorvindividual): 6Lr\ C-tOQ(- A+ COI\ CUa\OY\
Address: ®� \
City/State/Zip: � Olff Phone #: $.�,�- 7cA(5
Are you an employer?Checkthe propriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet.: 3• Remodeling
ship and have no employees These sub-contractors have 8QD Demolition
working for me in any capacity, workers'comp.insurance. S.�C1 Building addition
[No workLrs'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions
myself.(No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.[No workers'
comp. insurance required.] l3.❑Other
•Any applicant that chucks box#1 must also fill out the section below showing theirworkers'compensation policy infomtation.
t
Homeowners rs who submit this affidavit indicating they am doing all work and then hire outside contractors most submit a new affidavit indicating such
:Comnwton that check this box must attached an additional sheet showing the name of the sub-contractors and their worker'comp.policy information.
1 am an employer that Is providing workers'compensation insurance jar my emplayem Below Is the pulley and fab site
information.
Insurance Company Fame:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ufthe DIA for insurance coverage verification.
1 ria her=cundo painsrat enalt of perJ4 m he ' ormation provideed above is true madd correctSiena1 it > ^t�1` Date: / `6" �C j ASS
Phone#: `q3 ?— /P7/T
Oficial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/Lleense# _
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other .
Contact Person: Phone#:
CITY OF S. .EN1, 2NvL-1SSACHUSETrS
• BuILDIING DEPARTMENT
• 130 WASHINGTON STREET, 3"°FLOOR
TEt.. (978) 745-9595
FAX(978) 740-9846
(q�{gFRI.EY DRISCOI.L
MAYOR Tmomks ST.PrERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLVISSIONER
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 orh er)
The debris will be disposed of in :
(name of facility) U
(address of facility)
signature of permit applicant
date
debrirILdx'