23 PURITAN RD - BUILDING INSPECTION The Commonwealth of Massachusetts
QNINON
Board of Building Regulations and Standards Town of
'Massachusetts State Building Code, 780 CMR, T°edition Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a
q� One-or Toa-Fmndv Divelling ANN&
(„ This Section For Oficial Use Only
Building Permit Nu ec Date Applied:
Signature: & d y/Q
Building Commissioner/ln «tor of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pr rtAg�ress: 1.2 Assessors Ma & Parcel Numbers
o e
3y 9"r," fit. 1?-1P
L I s Is this an accepted street?yes_je no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) 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:
Zone: _ Outside Flood Zone?
Public 59'- Private ❑ Check if es❑ Municipal❑ On site disposal system 13
SECTION 2: PROPERTY OWNERSHIP'
2.t Owner of Ree d: pp ° p
/!1�r) v;Cc'-//p 23 Put,i T/9 M 0. d
Name(Print) Address for Service:
6) 78- 7 qct-
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) C3 Addition ❑
Demolition El Accessory Bldg.❑ Number of Units_ Other 13 Specify:
rief Description of Proposed Work': T u O !�
r'an [re.TP �4q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlcial Use Only
Labor and Materials
1. Building E C?(S V0, Vv I. Building Permit Fee: E Indicate how fee is determined:
L4Mechanical
lectrical E ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
lumbing E 2. Other Fees: E
(HVAC) E List:
5. .Mechanical (Fire E
ression Total All Fees: E
Su
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: 5 Y/5�470r V" 0 Paid in Full 0 Outstanding Balance Due:
i
ti
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 6 227 L/ (� ' Z 0- of
'6eorf-l— 0VyvOS License Number Expiration Dore r
Ngmc of CSL- Hplder List CSL Type lscc below)
�1d[ )fr,ti crag G��
T Description
AJJrcss
U Unrestncted u to 75,000 Ca Ft.)
R Restricted 1&2 Family Dwelling
ature r� M Mason Only
RC Residential Reefing Covering
Tclephone WS Residential Window and Sidin
SF Residential Solid Fuel Bumin Appliance Installation
D Residential Demolition
5.2 J,tegistered Hoar�I pr��ent Contractor(HIC) f (�U 3 2
Ho,
rQ
HIC Compan Name or HIC Registrant Name Registration Number
yt C�Jr4 d S—) I— /v
Address
Expiration Date
aturc 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 .......... O 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.
7behalf.
Date
CTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
nformation on the foregoing application are true and accurate,to the best of my knowledge and
Signature of Owner or Authorized Agent Date
St ned under the ams
and penalties of perjury)
NOTES:
I. 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 agf 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 I I O.R6 and I I O.RS, 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
J. -'Total Project Square Footage' may be substituted for"Total Project Cost"
CITY OF Sall.i:M, 2%LkSSACHUSETI'S
13UL DLNG DEPARTMENT
120 WASHINGTON STREET, 3w FLOOR
'ISL (978) 745-9595
FAX(978) 740-9836
Kj-tgFRi FY DRISCOIl
,MAYOR THO&W ST.PW-M
DIRECTOR OF PUBLIC PROPERTY/lIUM MSIG CO\L\DSSIONER
Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers
Aimlicant Information Please Print Leeibiv
Natnt: (Business.Oraaniratiorvind,viduul): .. tQf—S P r V/ n r L �h C 7f✓C. . t �h C
Address: `7 GJd'fiG(, crg -r n„j
City/State/Zip: ��1lPn, t MR Phone A: J9,Q— S/ S - qY 7r) —
,%re you an employer?Check the appropriate box: Type of project(required):
1.El am a employer with 4. ❑ t am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors & ❑New construction
2.❑ 1 am a sole proprietor it partner- listed an the attached sheet : 7• ❑Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. )+orkers'comp. insurance. 9. C] Building addition
(no workers'comp. insurance 5- (Z
We are a corporation and its !0. Electrical repairs required.] ot7cers have exercised their ❑ pairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGG I I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. LNo workers' l3.❑Other
comp. insurance required.]
'Any applicant this themes bot#1 must also fill uW the section below showing their workess'rompenaa dos policy infunnatien,
I hwneuwtwn who suhmit this affidavit indicating they ate doing all work std then hire outside eentrwiors must suhmit a nav affidavit indicting such.
=c'.tmracwn dot check this baa mwn anxhed an additiwd slw:t showing the nvne of the siib rontrwlom and their workers'romp.put icy information.
!um an employer that is providing,vorkers'compeasatlon insaranee for my emplayeet, Below is the policy and fob site
information.
Insurance Company Name:
Policy #or Self-ins. Lie. #: 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 Section 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 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. Ile advised that a copy of this statement may be forwarded to the Ofrice of
Invest%gat ions ofthe DIA for insurance coverage verification.
1 do hereby certify under the pains and penalties of perjury that the information provided/above is true and cornea
Date' (n ' 2s ' /
OJfcial use only. Do not write in rhh area, to be completed by city or town official
City or Tusvn: __. Permit/f.lccnse#
bsuing Authority (circle one):
I. Board of Ilealth 2. RuildlnL Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Cunlact Person: ., _ ___ ___ Phone 9:
CITY OF SALEM
ry PUBLIC PROPRERTY
4 1 !,
DEPAR"I'�IENT
I I I V'S 'JiXX. 'i7}r'4-•til„
Construction Debris Disposal Affidavit
(rcyuired lilr all demolition and rcnovaliun work)
In accordance ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris iesuIli ng front
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debt-is will be transported by:
/pyo lJ �y /��s
(name of hauler)
The debris will be disposed of in
yUR� r7—t n_C
( wmr of lacility)
W
At, 2 > (/�
(addres<of Iacllily)
.I• at ,rf Penna .g1phcant
,late