15 VISTA AVE - BUILDING INSPECTION (2) The Commonwealth of MassachusettsA 11
Board of Building Regulations and Standard ? �� -
I OF
Massachusetts State Building Code, 780 CMR SALEM a
1016 SEP �q greyt.&r2011
Building Permit Application To Construct,Repair,Renovate Or Demolis a
i
One-or Two-Family Dwelling
�( This Section For Official Us Only
Q Building Permit Number: - Da[e App ed:
n Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
t
s 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
� ,s+
1.1 a 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 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❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 OwnerofRecord• 1 r ,✓1A�/�_
a� S LLl
Name(Punt) City,State,ZIP n l
( S fit/ j _ D � '7L, lm!:-Address
'— /moi
No dStreet T' ele o T�� l ddress
„ SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) r,
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-2:
c
r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ .. Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ 13s
Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ `
4.Mechanical (HVAC) $ List: "
5.Mechanical (Fire
Suppression) Total All Fees:$
/ Ov Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ V/ ❑Paid in Full ❑Outstanding Balance Due: .
SECTION 5:,CONSTRUCTION SERVICES
5.1 Construction Supervisor Cot
(CSL) �` ,0 II..sZ �_
L^ "'t /(L�T Lice" nse Number E pirate
N of CSLHold
^ c� List CSL Type(see below)
actNo.and Street Type Description ..
4/ �//� U Unrestricted(Buildings u to 35,000 cu.ft.
1 _ -x-1- t/i* R Restricted l&2 Family Dwelling
leiiNybAstawrZIPM Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
�� I Insulation
Telephone Email address D Demolition
5.2 Registered Home farprov ent Contractor(HIC) Th 1-7
` 3 , , uiRbe
! HIC Registration N r E pimhon Da e
HIC Com any N or HIC Registrant Name
t �
No. d S 6 V6 Email address
i o ,State,ZIP 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 .......... 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 C-4,,.t ��
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature O Dat
SECTION 7b:OWNEW 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 th best o y kn ledge and understanding.
f C/ t
Printf wner's�ed Ag'fgent s Name o ignature) I f 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.gov/oca Information on the Construction Supervisor License can be found at y5n .mass.gov/dps
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"
CITY OF S.U.E.�1, TN'LkSSACHUSETTS
BUILDING DEPIRT\t&NT
130 WASHINGTON STREET, V FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
lu�{gFRt RY DRISCOLL
MAYOR T Homm ST.PIERxB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER
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 treansported by:
J (name of hauler)
The debris will be disposed of in
e (name of facility)
144
/ " I
ad ress of facility')
L-srgnature of permit applicant
date �—
JcbrivlT.JrK
u
�� � .��Iev �LnUro�R[.utaen���of r'l(.I�JJnf�tda�rJ a.
O[iice of Censuwsr Affairs&BusiSfts Regulation
OME IMPROV•,EMENT CONTIR, OR
egistrab1�
on: .y?13 Type:
xprration - 511120/7 _ Corporation
I
EMPIRE 1 HOME IMPROVEMM ETRSINC .�
CLI-- CALVIN
229 VERNON ST.
'�}'iD'•
.`•WAKEFIELD,MA 01880 Undersecretary
- Massachusetts Department of Public Safety
Board of Building Regulations and Standards -
License: CS-104865
Construction Supervisor n
CLINTON AGALVIN a++
9 PETTINGELL AVE. ,# '
ANDOVER MA 01810 .
V. y
V
ZU7 CA- Expiration:
Commissioner 0710112018
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): stwL•/�t!?,�rJ•— 1zN .n/.Yht
Address:
City/State/Zip:'
l Phone #: Cy 7
Are you an employer? Check the appropriate box: Type of project(required):
:
1. am a employer with t} 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. E] New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P Y• 9. E] Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions
myself o workerscom' right of exemption per MGL
Y P• loofrepairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: tl K ✓ C t
9� /1
Policy #or Self-ins. Lic. . L 0 Expiration Date:
Job Site Address: q'VUQ_ 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 $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 $250.00 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.
I do hereby certify unthe pa' rdndpenalties ofperjury that the information providedabis tru a d correct
Si ature: /i � Date: N/ I � 6
Phone
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
6 FRnFFR
memo — do *
�Rr
Submitted To: 781-606-1984 lob Locatloo:
Empirelhomeimprovements.com
Mr. Assimakopoulos 15 Vista Ave
Salem, MA
Pool& 979.7wolo
t0181F.
PMON1 tlate: lain 21,20118
Siding:
• Install 3/8"insulation board to house
• Install!channel,comers,starters as needed on house
• Install new Vinyl siding on house
�• Install new soffit
• Wrap all trim with white aluminum
• Install all new gutters to house ,,,ti
• Remove all debris related to work
—• Re install shutters
—• 013tion: install new shutters to house
• $95 per pair
ACOS[d8t8i�$ [_Deludes cost of ermit,laboq d_u_m _& material _— ___ — „_ _ Peymellc$ebedUle:
Overlay siding price: $9,400 1'r payment due upon signing: $4,000
Remaining balance due upon completion
IMS99811V SUbmined by AtxUOtetl bn'
All work is 100%guarante f on all craftsmanship. All other warrantees are through them cturer. warrantees will be null&void if
job is not paid in full.Thank you for letting us serve youm Empire 1 Home Ifnpi enrents, Inc.
_l
l