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BP APP 16-966 BATH V D 35 -7 The Commonwealth of Massachuse,' t l� Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 7 CMR SALEM A!'G ^ Revised Mar 2011 Building Permit Application To Construct,Repair,Renova e e lis aj One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: D pplied: "(1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Pro erty D Address: '4& t V� 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 R) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water upply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: — Outs utside Flood Zoye? Municipal&(/On site disposal system ❑ Check if yes SECTION 2: PROPERTY OWNERSHIP' 2�1, caner'of Rgeo� M Pi 00 70 (1'fialLGVt Name t) City,State,ZIPF No.and St#et Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKz(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work : - rim SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Offsial Use Only (Labor and Materials 1.Building $ b Q 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ Q 12 E3Standard City/Town Application Fee V ❑Total Project Cost;(Item 6)x multiplier x 3.Plumbing $ Q00 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ , Do 0 ❑Paid in Full ❑Outstanding Balance Due: Gt=I,L : q-Lo - %c)4 - 9 (0-16 G .C, I SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) (�—o&73q 95 & ]l�}yyt e L License Number ExpvaS tion D e Name of CSL Holder r� 19 - ^�� List CSL Type(see below) No.and Street 't T Description Unrestricted(Buildings up to 35,000 cu.ft.) `7 Mf fif tit 1"` l l Restricted 1&2 Family Dwelling City`town,State,ZIP M Masomy RC Rooling Covering WS Window and Siding SF Solid Fuel Burning Appliances N -365-q 1jd7 r(-jC01 191TW6OK401 I 1 Insulation e2p one r Email address D Demolition 5.2 Registered Home Improvement Contractor(MC) --721 �2 MAMG G* C- egistrath r Expiratio Date C Com y Name or HIC Registrant Name No. r freer E 4�l iN6 ' i1£T NF j i.EtM MA, ©��[/ -M-"?0q—%7A Ema l address Ci /Town,State,ZIP Telephone v SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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 > I,as Owner of the subject property,hereby authorizeI7r"Yli to act on my behalf,in all matters relative to work authorized by this building permit application. PriFt er's ame(Electrons Si a Date SECTION 7b:OWNER'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. Z 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(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. ov/oca Information on the Construction Supervisor License can be found at mnD .mass.gov/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"maybe substituted for"Total Project Cost" CITY OF S�UX.N21, iNv•LxSSACHLSE= • B17LDING DEPAR-D(ENT 130 WASHINGTON STREET,Ya FLOOR TEL (978)745-959S FAX(978)740.9846 Ki,.%iBERLEY DRISCOLL It LLAYOR ioMas ST.PiERRs DIRECTOR OF puilt iC PROPERTY/autLDnTVG comxaSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Vattte(Buzi>KsvO/rganizatioNlndividual):Q FC ldiy7 "A-16 lAff Address: / I -S &/M/�,j ?✓F, p� City/State/Zip: � .�i�m MSA. Of °1-70 Phone #: 2 ?1,0�"- Aro you to employer?Check the appropriate box: Type of project(requireM: L❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑N construction �mployees(full and/or part-titin).• have hired the sub-contractors 2. 1 am a sole pmpriemr or parmcr- listed on the attached sheet.: 7• Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 t.❑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' 13.❑Other comp. insurance required.] •Any appacam that fiats bine kl mast also fill cut the sectroo below showing their workers'compensation policy information. t 1 htmeownets who submit this affidavit indicating they ate doing all work and then hire outside contracnota most submit a new ain avit indicting such :Contnawn that cheek this box most attached an mlditional duet showing the name of Ma subcommctors and their wodwsa'camp,policy information. 1 am an employer that is providing workers'compensadon insurance jar my employees. Below is the policy and Jab site nrmarioa * ' I Nl� N S m Insurance Company Nae: {�T� 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 Station 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 imprisonmenk 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 of the DIA for insurance coverage verification. 1 do hereby edify under the pain�spand penaldes of perjury that the injarmadon provV d abo v Is true and come[ . i gn t re 41-1- BOJ Date• O k9 J�� Phone#: q-71- >q S 367 / OJJleial use osdy. Do not write in thkt arca,to he completed by city or town officiaL City or Town: PermidUceme# Issuing Authority(circle one): 1. Board of Ifealth 2.Building Department 3.Cityffowo Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#' y � � �. ' y \ ,. , � a� ' �ti'�� ` �� r � ' � '! �' �—` �,.� ' � �_ r ,�_ ,. �� F J \\ I �aK, �^iv' i�' � \ - � '. � `_ 'i CITY OF SM.F.M 1N'LkSSACHUSETTS BUILDLNG DEPARiNmNT • 130 WASHNG[ON STREET,3� FLOOR TEL (978) 745-9595 FAX(978)740-9846 KI\IBERLEY DRISCOLL MAYOR THonus ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUUMING CO\5MIO ER 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 of hauler) The debris will he disposed of in : �GL D ee�c j>y�lg/-'7 i y (name of facility) (address of facility) signature of permit applicant L�6 date dcbriwlydm