26 BUENA VISTA AVE - BPA-16-1046 S25 ck q61IR F CRTp
ILI The Commonwealth of NfiRL WAL
- h Board of Building Regulations and Standards CITY OF
Massachusetts State Building) d 0 qrP SALEM
L z7—I" 12' � 4 Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official UseOnly
Building Permit Number: Date Applied:
�Y Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
26 Buena Vista Ave
1.1 a Is this an accepted street?yes X 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 rr'1I Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
—7( Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
William Doane Salem MA 01970
Name(Print) City,State,ZIP
26 Buena Vista Ave 857-212-9580 billdoane1@gmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other a Specify: Insulation
Brief Description of Proposed Work': Air Seal 8 hours,install door sweeps and weather ship,install 52 pmpavents,thenal barrier to attic hatc ,
Vent bath fan to roof flapper,insulate open attic with blown in Cellulose to R38, Insulate rim joist with FB batting,install
961in ft of damming
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 3,401.59 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(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: $ 3,401.59 ❑Paid in Full ❑Outstanding Balance Due:
fsoaD TO �l • C7 .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CSSL 100454 6/13/17
Glenn Alexander License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
25 Bond Street I
No.and Street Type Description
Reading MA 01867 U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
781.397.9909 gja06l3@gmaii.com I h sulalion
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 188085 1/23/17
Alexander Insulation LLCHIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
25 Bond St gja0613@gmail.com
No.and Street Email address
Reading MA 01867 781.397.9909
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 ..........0 No...........❑
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Gleno Alexander
to act on my behalf,in all matters relative to work authorized by this building permit application.
9ti y--1 (p
Print Owner'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
contained in this application is true and accurate to the best of my knowledge and understanding.
T. /L/ /6
Print Owner's o Authori ed Ag is arae(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(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 www.mass.gov/dps
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 Cosf'
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
U,krkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aoolicant Information Please Print Leeibly
Name (Business/Orgmization/Individu 1): Alexander Insulation LLC/Glenn Alexander
Address:25 Bond Street
City/State/Zip:Reading MA 01867 Phone#: 781.397.9909
Are you an employer?Check the appropriate box: Type of project(required):
L❑I am a employer with 3 employees(full and/or part-time)." 7. ❑New construction
2.[]l son.sole proprietor or partnership and have no employees working for me in g, ❑Remodeling
any capacity.[No workers camp.insurance required.]
3.E]1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
5.M 1 am a general contractor and 1 have hired the subcontractors listed on the attached sheet. 13.❑ROof repairs
These subcontractors have employees and have workers'comp.insurance.
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.®Other Insulation
152,§1(4),and we have no employees.[No workers'comp.insurance required]
.Any applicant that checks box 41 most also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Zraractors that check this box must attached an additional sheet showing the name of the sub-contracmrs and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Berkshire Hathaway GUARD Insurance Company
Policy#or Self-ins.Lic.#: ALWC796181 Expiration Date:7/29/17
Job Site Address:26 Buena Vista AVe City/State/Zip:Salem MA 01970
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the painssannddppeennalltie�s ofperjury that the information provided above is true and correct.
Signature. � 2 Date: 940 /i�
Phone#:781.397.9909
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: