1 HARBOR ST - BPA-15-1315 ROOFING t 381LJ�* CK1983
'rhe Commonwealth of Massachusetts 4iy OF
q / Board of Building Regulations and Standards R CEI oSAI I
i irr
Massachusetts State Building Code, 780 CMR I)ASPECT l )Revised ititjr1&H
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Avo-Family Dwelling 1015 NO 3 0 P 2 12
n This Section For.Oflicial Use Ont
(v1 Building Permit Number: Date.A [led:
Ln 7Duilding 011icial(PontName). Signature' ' Date
,
SECTION I SITE INFORiMATIOW
1
1.1 Pro irty ddress• 12 Assessors Map S:Parcel Numbers
riper sr
1•l a Is this an acce ted street9 yes no blap Nwnber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District -' 4 Proposed Use - [.otArrr(sq R) Frontage(R) -
1.5 Building Setbacks(D) .
Front Yard - Side Ywii+ - Rear Yard. .
Required Provided Required Provided Requited I
. Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 - Private O. Zone: _ Outride Flood Zone? Municipal O On site disposal system O -
Cheek If es❑
' SECT[ONZ: PROPERTYOWNERSR1Pf, `.,'
t
�
1 ( j n�f �P/1/t 1 City,Shite,ZIP
6sz ' P. rte, Jl
No.and Street —' - Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK;(cheek all that apply)
New Construction O Existing Building O Owner-Occupied a .Repair (s) O Alterotion(s) O Addition O
Demolition 13 Accessory Bldg.O . Number of Units Other O Specify:
Brief Description of Proposed\York':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs' Oflfeial Use Only
Labor and Materials
I.Building S (� : 1. Building Permit Fee:S- indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost?(hem 6)x multiplier x
3. Plumbing S J?Qther Fees: S
4.1%In:hanical (FIVAC) S List:
5.i\Nchanical (Fire S Total r\II Fees:S
Suppression)
Check No. Check Amount: Cash Amount:_
G.Total Project Cost: S 00 ❑Paid in Full ❑Outstanding Balance Due:
7a 3106 CSSEk ��-
SECTION 5: CONSTRUCTION SERVICES r
5.1 Construction Supervisor License(CSL) if l ��� Q—7 —J�
("/Fhj �Ql�)�k N License Number EspiralionDate
Name of CSL Holder List CSL'rype(see below)
�0 6 �s-i-mac S
Nu.:md Street - - Type - Description .
U Unrestricted(Buildings Lip to 35,000 cu. 11.
�{
,/ u/ D�C t)1 I R Restricted 1&2 Family Dwelling
Cityfrown,Statet ZIP M Masonry
RC Rooting Covering
7 Gr L77 WS Window and Sidins
/�J J [I O J G.3 1 Inslid ulationl Burning Appliances
Telephone Email address D Demolition
5.2 Registered Home Improv, ment Contractor(HIC) IS-L763 _
G . T1��fV yk - HIC Registration Number Erpimlion Date
I I IC Cuywany
"S(J�Nam• Ce
iyr ^-
4/(�✓. h)ti6 ,iy1
NMA&A ^^ ( ,2 �J Email address
Ci /Town State.ZIP VJ Telephone)
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G,L:c:1$2:§25C(6)y,
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...........0
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 b/r� a-4m '
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nano(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED 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 th t of my knowledge and understanding.
Grp 5A-)V4,/_0 /r,2?'/3`
Print Owner's or Authorized AgcWs Name(Electrons Ware) 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 n have access to the arbitration
progearn or guaranty fund under M.G.L.c. 142X.Otherimportant tnfoimnfion on the HIC-Program canoe be — —
www.mass.eov.'oca Information on the Construction Supervisor License can be Pound at www.nms� .
2. When substantial work is planned,provide the information below:
'rotas floor area(sq. R.) (including garage,finished basementtattics,decks or porch)
Gross living urea(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
'rype of cooling system Enclosed Open
1 "Total Project Square Footage"may be substituted for"'fatal Project Cost"
The ComrnonwepUr ofMarsachuseds
Department oflmdustrfdl Accidents
1 Congress S7vee4 Suite 100
Boston,AM 021141017
wnmsmAMgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contradars/Elecbiclans/Plumbers.
TO BE FILED WITH THE PF.R1 UnMgG AUTHORITY.
ApplicanthibrInation
Na=(BusmessOWmirehon%f AWausl). . .
Address:
City/Stste/Zip: M C O / 'vq Phone#:�01
Are you m empioW.O wk the pppnprJtte bar: Type Otprojtx#(reyaired):
1. I 09 employer atiPor (full�d/o+P�- )'- 7. 0 New construction
2.07am e,sck pmpviefaorpartaaship�sdhave no employereworl,ring forme in S. 0R,emodeling
myeepadty.No wurk®s''e�.fviaoanee ietpt6ed.J 9. 0
Demolition'
3.q!am a homeowner dabs an wo*mYwff.1110 worlws'Mov,Wu'regn1 wdd)t .
10 p Bin7ding`sdditiun.
4.Qlamahou*Dw wmdwdlbehbiagcoomctmmcondoranworkmmyproperty. lwell
emrm that all coffiadon eidWhave wmkas'mmpeaM1hon inaaaocearate sole 11.0 Electrical repairs or additions
paomaots wn mmyl^yea. 1z:pPlllmumg imus
or eddmims
S,C)Imagennalecimendlhne afiad�e arskootraetmr lidteA on Poeattiehedahee"t iJ oof . ...~
7hmmb.conmwimbmemploym adbawworkm cep.ina�mf �
6.0weareacotponstim trod cls officeishweeserciaed thearigat ofesempfianpaMQ.a 14 fOthcr
152,¢1(4),cad sxaaltiroemploY�=lHo wmkeis'Cmsp:�IDsivmce requeedl.-�� -
•AWappliemfffiet eheel®aca iYl moat deo$Bom>be aeetloabebwahowiog>bea workaie Pahe7' .
r Hotoeovintas who autmrt Pois affidaiit mdieefmg Lary are chug as work tbmhve outside malmdasnnrst aolmit a new atfidevitntd encs:
iContraoton that check"au m n attacked aaaddiuoml daddmwrog tim—at'dw sub-mhnzc&ii ad state"beam mum ffioreentaws have
employees ffOe sub-Quad tbeee,emp]_oyeeq they must puovidettx5r.wmkas'camp.celiry a-: - ..
I am aR mykyer OWJsprotiding w*rkers'coagpeusafion fargrmwror m3'espjta!yeea. Below a Skepolli7a�rdjob
krjonnoNon. n��
Insurance Company Name: �1
Policy#or Self ins.Lic.(# i)j C C '9qle 10/�— Expiration Date.-
Job
ate:Job Site Address: /c ivy, –T city/3tatevWx
Attach a copy of the workers'compensation poBey dedamdon page(showing the policy number and expiration date).
Failure to secure coverage asiequired under Ma c.152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year irnprisonmeob as well as civil penalties in the form of a STOP WORK ORDER end a fine of up to$259.00a
day against the violator.A copy of this stateinmt iuey be forwarded to Ste Office ofloveshgaticas.ofthe DIA fm innuance
coverage varificatioa_.
Ido b®eby eerrify pains and penakles ofperjury that She informadon provided above is true and eom?a
;.�. / Date
Ph e
r601ber
W use only. Do am wrke In this area,to be coeydefed by 4 or town o,Qlcw
or Town: Permit/Iicense#
ng Authority(circle one):
ard or Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
act Person: Phone ft
l
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 employer,or the
receiver or trustee of an 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 of the
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 an employer."
MGL chapter 152,§25C(6)also states 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,§250(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 conplience with the iosmance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-camtractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited liability Companies(LLC)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 be sure to sign and date the affidavit 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-insuredcompanies should enter their
self-insurance license number on the-------isle line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department 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 peamitnicense number which will be used as a reference number. In addition,an applicant
that-must submit multiple pernrit/licrose 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 ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for futre 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 coffirhercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax 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
" QTY OF SALEM, MASSAmUSE'I'TS
BuIIA7NG DEPARTMENT
120 WAsmNGTONSTREET,3'mFWOR
7tL.(978)745-9595
KIMBERLEYDRISOOLL FAX(978)740-9846
MAYOR THomm ST-PIERRE
DIRECTOR OF PUBUCPROPERTY/BURDINGWI MISSIONER
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
Lyng
(name of facility)
(address of facility)
Signa re of applicant
Date
I
µ Massachusetts -Qepartment of Public Safety .x
8ri&rd Of t3uililing Re9006ns and Standards
Gunstruction Supervisor'syecislh
License CSSL09967
f. iKJA~
.r 'x'30$;p, SSIrX STBEXT s
tfPScflTT 14A
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Expiration
Commissioner 04x22/2016 "
. —,.,____--`— CT'ee �pmnmaonweall.�z c�P/�.aaoor»4uaelrs`.
I - Office of Consumer Affairs&Business RegutBdoo
fOMEIMPROVEMENT CONTRACTOR ,
egistration g9g3g Type: y
' xpirabon DBA - F
G.JANVRIN HOMEl1NfPf HT'
. . it T
s -
PLEN JANVIR
S06.ESSFJt ST- q h
SWAMPSCOTT,MA 01907 Undersecretary
Restricted TO: CSSL-Ws-Windows and Siding
CSSL-RF'Roofing .
Y
2 Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
,For DPS Licensing information visit: www.Mass.Gov/DPS P