87 MASON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
1Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7th edition OF SALEM
/I r' RevisedJanuary
Building Permit Application To Construct,Repair,Renovate Or Demolish a I, 2008
One-orTwo-Family Dwelling
+ is S ion For Official Use Only
' Building Permit Num r � Date A
/A� /
Signature: °06no
Building CommissionegMnspecto&Wings Date
CTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers ,
87 Masan S-V
Lla Is this an accepted street?yes X no Map Number Parcel Number
13 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 16 Private❑ Zone: _ Outside Flood Zone? Municipal VI On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP
2.1 ` N G W Owner of Record: ``'' - 1
9,1h ;AY\a-�o Y\ C', K 8 7yVlacor S�"
Name(Print) Address for Service:
978 766 N3 `f I
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Constriction❑ Existing Building N Owner-Occupied 0( 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of ProposedWork2: rto�a� 5t�coorn5
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ &.CO a 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 1,600 ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 5.S010 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ w{(a p ❑Paid in Full ❑Outstanding Balance Due:
g�00 ' 9�8�3��- 035
11i"k c(p
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
0666o3 5-6- 1Z
License Number Expiration Date
Name of CSL-Holder
1 Y 2 SQI rM A List CSL Type(see below)
A C re s5 0197e (>
Address Type Description
U Unrestricted( m 35,000 Cu.Ft.
�-= �' R Restricted M2 FamilyDwellingf f
Si re - M Masonry Only ,y
97 B-7 3 S -03 S 7 RC Residential Roofing CoveringT
Telephone WS _ Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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 ..........30 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner - Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, Tn M�3oo as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
-54v.,.a-s Hr�rr.e eo�
PrintName��// '
/912
Signatur of Owner or Authorized Agent Date
(Signed under the pains and penalties of
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 nm have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.86 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
f CITY OF S.UENI, 1WSACHUSETTS
BuMDMG DEPARTJWNT
120 WASHINGTON STREET,r FLOOR
arj
TEL (978)745-9595
FAX(978)740-9846
KJ5ffiFRT EY DRISCOIt
i�1AYOR Il'ioltlAS ST.PD:RRRH
DIRECTOR OF PLB11C PROPERTY/11URDUNG COaDIISSIO.iER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbm
Applicant Information Please Print Leelbly
Name(Business Otpaintiomlmiividual): .-'f'•({$
Address: 4 c mi6i ewe.
City/Statl:Mp: Sq6n AA 01970 Phone M 97 8 - 7,'? o357
Are you an employer?Cheek the appropriate box: T of
Ylre project(required);
I.Q 1 am a cmployer with 1 4. 0 1 am a general contractor and 1 6. 0 New construction
employees(full and/or par-time).• have hired the sub contracmts
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These sub-contractors have & ❑Demolition
working for me in any capacity. workers'tongs.insurance. 9, ❑Building addition
(No workers'comp,insurance 5. ❑ We are a corporation and its
required.) officer have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 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' I3.❑Other
comp.insutatice required.]
'Any applisaul that chats tan#1 must also iia mut the section bclm Aquino tbelrwmktas'oompensvion policy miannadun.
t lhnttrawaa who submit this aaidm it indie[ing tluy are doing ail work and than hire outride co nrulm rom submit a urn affidavit itdl wag such
:Co"OU xota that check this bone nima atlacbed an addawma shat amwing the o,m,ordw mbsommoq,,and their wmimrav camp.polity iofmtmtltm.
I ora arc employer that is providing workers'compensadon Insurance for my employeem Below is the policy and Jab sits
information. 1
Insurance Company Name: 1��U\Ue v-t 11 VV ,3%to.\
Policy#or SolPins.Lic.#: WC-2 - 31`3. 377 255 - o I d Expiration Date: `4 - 1 9-l i
Job Site Address: 9"7 M r.eon 5:� City/State/Zip: 5Q(eoi MA o1970
attach a capy 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 S1.500.00 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 ihata copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby certify under the pa has and penalties of pedory that the hirorma don provided above is true and correct.
Signature: � (,,) • Date: /- fl-/(
Or
Phone#: 478 735 0357
acid use only. Do not write in this area,to be completed by city or town offichst
City or Town: Permitillcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
ContaM Person Phone#
r.
i CITY OF Sm3LEi�1. XWSACHUSETTS
ButimLNG DEPARTsffiNT
j 130 W ASHNGTON STREET,r FLOOR
TEL (978)745-9595
FAX(978) 740.9846
lCl�(BERIEY DRISCOLL
MAYOR THOMAS ST.PWAM
DIRECTOR OF PUBLIC PROPERTY/Butt.DiNG CommiSSIONER
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 be disposed of in
—C—cw.?fur S��,o✓t
(name of facility)
0.
C e—yyt ■ctt A
(address of facility)
,//signature of permit applicant
date
dctrjwr.dix