28 CLIFTON AVE - BUILDING INSPECTION (2) 00 �r^7N �t✓c S2-7'�) S
The Commonwealth of MassachusettsCITY OF
Board of Building Regulations and Stands AC :, (SALEM
Massachusetts State Building Code,780 C77pM����R Revised Mar 2011
Building Permit Application To Construct,Repair,RenoVEtdt i�c1b"blifPa
J One-or Two-Family Dwelling.
Q - Tbis s..etn For D use
� Building Permit, er: nate A)ap3iad:
lb;��ng ,:;ertPr;at � she TTS
s�cr►oav i_:sIT�»o> IATioly
I— 1.1 Pro �A�dyEss: A�l, � 12 Assessors Map 8c Parcel Numbers
r n rlV�i �/CaYt
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District proposed Use Lot Area(sq it) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Regdaed 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? Municipal 13 On site disposal system 13Public❑ Private 13 Zone:
if yes13
SECTION 2i PROPERTYOWNERS11-W
2.1 Owner]of Record:N0 rl M C� /)`,
Name ' t • b + /DIC City,State,ZIP �q/ /rte -�? `4y1✓
t C42 >'q�,t-o- t -.-�T�
No.an Street Telephone Email Address
SECTION 9t DESCRIPTION OF PROPOSED WOR]e(check antis[applY)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief escnption of Proposed World:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only .
Item abor and Materials
1.Building $ O00-
1. Bui]tling Permit Fee $ Indicate how fee is determined
0 Standard City/Town:Application Fee
2.Electrical $ 0' O C]Total Project Gusts(Item 6)x multiplier x
3.Plumbing $ o 2. Other Fees:
4.Mechanical (HVAC) $ G v List'
5.Mechanical (Fire $ � ._� Total All Fees:$
Suppression)
Check No. Chock Amount: Cash Amount:
—
6.Total Project Cost: $ Q o b ❑Paid in pull ❑Outstanding Ballance Dw. .
$� /A klm M u2SM i T-1 j7e
5r&1C;VS
�L MAtUM '�Iz2-
SECTION 5: CONSTRUCTION 9MVICES
�5. Coonnstruction Sup{revisor L/ic se(CSL)
C,t7 1 n ! rQ 1���Q� Licensel•Numberr Expiration Date
Name of CSL Hdlddr,/.'
List CSL Type(see below)
No.and Street - 7vpc- -
Q.(! 4 UJ hi Gl d l Q U I
UnresRestricted
l din u el in 000 cu.ft.
9 R Restricted l&2F iDwelling
City/Town,State,ZIP M
/ RC - Roofing Coverin
- WS Window and Siding
�4 r N SF Solid Fuel Burning Appliances
JA 9-R �fG�� " /D/V4 fI Insulation
Telephone Email address I D I Demolition
5 Re ered Home improvement
Contractor(HIC)
Nom_ HIC Registration Number Expiration Date
HIC Company Name or HIC Re t arae
5-c— HQMrn��SJ✓! 7C �l2
No.and Street Email address
�avuuS
Ci /town to ZIP Tel hone
SECT TON&WORKERS-COIL MM ATTON MURANCE AFFIDAVIT(M.G.L c.151.§25Q6))
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...........D
7at OWNER AUTHORIZA TO 819 COMPLETED WHEN
OWNER'S AGRNIORCONTRA
C/T�®R VVHaM]PER
1,as Owner of the subject property,hereby authorize J/D M A 1.Oa A/ Aril iz!i
to act on my behalf,in all matters relative to work authorized by this building permit application
lUBray� lin S� k 'L.. . ( (li
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'Olt AUTHORIZED AGENT DECLARATION
B entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con e n this application is true and accurate to the best of my knowledge and understanding.
C- iro clo /�D c� /11 (,
t Owner's or Authorized Agent's Name(Electronic Signature) Date
NQTE3 .
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
Mny.mass.uov/oca Information on the Construction Supervisor License can be found at wwtv.mass.eov/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"
�\ Office of Consumer Affairs& usin s egul
BesRation
OME IMPROVEMENT CONTRACTOR TYPE
I IN
egistrouon: 1.82496_ Corporation
xprrotion.
T �- lxfl!
` PRIDE CONTRACT1701 _ C,N
"-
ii v=
PEDRO MALDONAtj6 �
.: X31 GUILD RD v Undersecretary
�SAUGUS,MA 01960
P y
- ro alien P 's-
ubhc5ate„
o- Ma'ssaGhusetfs Dep ulations and Standar
#rd
Board of Building Reg . • ,..
4294'
:License. CS-1*
COnstiuctioh Supe
rvisor ,
rt
PEDRO MALDONADO -
Sr.HAMMERSMITH in
SAUGUS MA 0180f .0
Expiration:
03H0120%
- Commissioner
07YOFSALEA4 MASSAQME77
Brua�DBra�rr
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7��7*s-'3995. •
Fex 740-9W
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Dnmczmcippuuwprakmlxuuxwcomumcmm
Construction Debris DisposaiAffrdWit
(required for all demolition and,.renov 'tion work)
in accordance with the sbM edition of the State Bulking Code, 7W OAR, Section 111.5 Debris;
and the dons of MGL coo,s 54; Building Permit nY is issued with the
condition that the debris resulting from this work shah be disposed of in a properly Incensed
waste deposit facility as defined by MGL c 111,s 156A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
\JKvka
(name of facility)
(address of facility)
Sig ture of applicant
Aa
Date
Date
The Commonwa*h ofHassa0owns
Dep ext ojlndrrsjWaAcvdents
I Congress S7f r4 Suite 100
B.oston,M4 02114-200
rmmtmaxygov/dfa
WJWorkers'Compensation Insurance Affidavit Builders/Contractora/Electdclaas/Plumbem
TO BE FJL:FDWJTH TBE PERM KIM NG ADTHOR1Ty.
Name(BnsmessMquilration/bMWuan: l Al- A7 L.
AddmsS:.!j !" (Lf/�/)7t�/ j/✓l. �Il 7YiJA� f3Q.0Ay S . 171-I� O l L b Y
Elynate/Ztp,: Phone#:
Amy"as em IoyerT Cbwk the aPpmPrtaee bur:
1. a emalay«ra.rim. (rolld/orpwt-time)•' 7. O New
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2.Qlaa,aole}aopairorymmvahiy -0060W"evorling rmmem
myeapaeity(No natae''e�y.toaosoee l
3.p,amalmmw,mvdm92l1wm nYWJf Plow be oam,ms�caoa,eperedlt 1 DD�litibn,
I0 p Building'edditim.
4.O1®abomeowaerand�bebiftaamaumaroso fa0wakmmypoverty. lWO
emaePomanunhadmeiawhmwmtms'mn aonmaaanaeareaok 11.QBlecuicaln�sorsddifiens
pmpieton witbaoeaployeeq .. - 12: P
ad .068�] hmlbmg tepmta
5.01amagmeml eaasadar and/havb h&ed'8ie euti-eaariae6otafiteed am�a.nirMdaLoer: is. Roof -
. ]bea.atbroonnsawm Neve employro andhave wodrm'amp.amasawt- �: ..
6.0 we aneaco+pomdonmditt offieembaro esexisrd Potsrit ofeapcMGl.e. 14.QOPoer ..
737,41(4),and weliarem employees:pio WMb s'bump � ) -
•Avyappnrm[Poetehwiabm lmWtaleoW�t the sect oa bebw*bwfgS**-"_' a mpohey m
t xomeowms who anlrnib cob affidavit ia�iriibg tory eiedob'og,n wa&!F®d mm bve aotlaide ea�wae const aoboi$f new e�davuo#aoos eutih
tCannacmla that c6arYtbiiBm teaached a.-oddido5al eheeJsh?wotB E;oJa�e ab-cm6otiurs awldme Itietoi nd�me amili's cove
emploreas..xme.Bubcpgppdaplmve®pJ.oyms�x�taw;deme6sys+comP•Poliq'm�tiq. � :- - ,
IamagewploYcrtbar+syrorltling>Nvrlre+s'ro�P on *'t�relorrajre�pl 8elawbthepaliryOWN Me
(njom�atfoa
Insmence Company Name �S Y O- Zrt
Policy#or Self-ma.Lic.# �Sd O,0 5-?- 'w3 Btp moon Date: ( 2 2 (o
Job Site Addrawa_) h
Attach a copy of the workM1 eompeesation policy declaration page(showing the policy number and esplrsdan date.
Fahure to acerae cov ere under A40L c. 152,�25A is a erivanal violation puni"le by a fine up to$1,500.00
and/or Ono year as well as civil penalties in the form of a STOP WORK ORbBR and a fine ofup to$250.00 a
day egamat fit? ohitor.A of"sWanient may be forweided to 9ie Office efloveadgetions.ofthe DIA far insurance
coverage " ention.
Ido h certify Aepains andpen ofpcowy that the informadon provided .. is a and eorrerL
t7 lG
IM
Phone
0,0kW ate only. Dona Wrke in this area,to be aA.Vlded by W:or towm offidaL
City or Town; PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CRyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,
express or implied,oral or writtep"
An employer is defined as"an individual;partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employe,or the
receiver or trustee of in individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant ofthe
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be eco employer."
MGL chapter 152,§25C(6)also slates that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please 511 out the workers'compensation affidavit completely,by checlomg the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)namc(s),address(es)and phone number(s)along with their cartifiwte(s)of
insurance. Limited Liability Companies(I L-)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. if an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also he sure to Op and date the aflidavie The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate lime.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Deparment has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the perroMicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitthcense applications in any given year.need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy ofibe affidavit that has been officially stamped or madoed by the city or town may be provided to the
applicant as proofthat a valid affidavit is on file for firtine permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fiur number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017.
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia