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8 WEST AVE - BUILDING INSPECTION
TISeConttnontvealthoftViassacitnsetts RECEIVED CITY OF Board of Building Regulations anAkR &NONAL SERVICE SALEM State Building Code, 780 CMR Revised Shir 2011 Building Permit Application To Construct,Repair; MON OrL a Iija al I One-or Two-Fmnily Dwelling This Section For Official Use Only : Building Permit Number: Date .pplied:: Building Ottkial(Print Name). Signature•: Date SECTION l:SITE INF0R1'V1AT10N LI Property Address: 10 )5C o�J 1.2 Assessors tNlap&Parcel Numbers ir.1ESY 1.1 a Is this an accepted street? esno Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Loot Area(sq It) Frontage(It) 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 13Private C3Checkif es❑ Municipal Cl On site disposal system ❑ SECTION 2: PROPERTYOwNERSHIPI` 2.1 Owner'of Record: _7VdA) 7-KACZ0K Sflt.Er11 40 0IR76 y'me(Print) City,state,ZIP g 1y�sr s7' 978-7W- 5�/ No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED wORW(check all that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units .7 Other VSpccify: djA#7H61C)ZRTI0A1 Brief Description of Proposed Works: ,LA)Sdd7E au» 6tn6a WOUf Wtr•H RWWA/ C4UULAOS'.E SECTION 4. ESTLNATED CONSTRUCTION COSTS Rem Estimated Costs: Official Ilse Only Labor and hlaterials t. Building I $ t. Building Permit Fee:$ Indicate how fee is determined: 2.Etectrirn! S ❑Standard CitylTown Application Fee ❑Total Project Cost'(item 6)x multiplier x 3.Plumbing $ P ether Fees: S At.klech.wical (IIVAC) S - List: L6, 'rotal \Icchonicsd (Fire S total All Fees:S t rY55iun) Check No._Check Amount: Cash Amount: Project Cost. .S R67y O0 ❑Paid in Full Ci Outstanding Bakince Due: gip SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) _ BRAD DANQFF License Number ` Expiration r3/o/Date � N:imo ot'CSL Holder List CSL`rype(see below) U - i,S ntAR/onl RD No. ®id Street Type Description . /Qkf jfirin l A U Unrestricted(Buildings tito 35,000 cu. 11. R Restricted M2 FamilyDwelling City/fuwn,Stute, 1� I M I Maso nry RC I Rooting Covering WS I Window and Siding SF Solid Fuel Burning Appliances t7 S�1-6At f Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /C� jD � �"JS 57-r.,1, Lin)�� t� " HIC Registration Number Expiration Date HIC CuiTo1,1r1C sRePtrunt Name 37 No. and Street - Email address �,�. o.0 6/?-s9�-6Br9 Cit /Town, tate ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G.L a 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 Is$uance of the building permit. Signed Affidavit Attached? Yes .......... No...........13 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED_WHEN OWNER'S AGENT OR CONTRACTOR, 'PPLIFS FOR BUILDING PERMIT' 1,as Owner of the subject property,hereby authorize 57-ICC.4 ( aOMT . ro t9 act on my behalf,in ail matters relative to work authorized by this building permit application. vjq� !l-S"-B- Pr' Owner's Name(E imine Signature) 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. /hS-lS 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 Ligol have access to the arbitration program or guaranty fund under 1t.G.L.c. 142A.Other important information on the HIC Program can be found at www mass.•oL 4;!GC:1 Information on the Construction Supervisor License can be round at+wv+v m:r, ov�los [Number When substantial work is planned,provide the information below: otal floor area(sq. ft.) 4 (including garage,finished basement/attics,decks or porch) ross living area(sq. it.) Habitable room count of fireplaces Number of bedrooms umber of bathrooms _ Numberoflmlf/baths pe of heating system Number of decks/porches pe ofcooling system_ Enclosed Open 1. I'm at Project Square Footage"may be substituted fur"rota) project cost, 4. The Commonwealth ofMassaclutsetts Department of IndustrialAcciden4s Office eflnvestigations , 600 Washington Street Boston,MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlcians/Plumbers Applicant W-ormation Please Print Legibly NaMC(Husineas/OrganizationMdividua0: rt. ne A Address: . 71, WA1�,(d!(rs.Yi At T City/State/Zip:/Y/ A( ,(4" aVff Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1. l am a employer with__ 4. I am a general contractor and] 6. [)New construction employees(full and/or part time)' have hired the sub-contractors 2.© 1 am sole proprietor or partner- listed on the attached sheat. t 7. [}Remodeling ship and have no employees 'these sub-contractors have 8. [] Demolition - working forme in any capacity, workers'comp.insmanm y. 0 Building addition (No workers' comp.insurance S. We are a corporation and its 10.0 Electrical repairs or additions required-] officershave exercised their 3,❑ I sm a homeowner doing all work right of exemption per MGL 11.[)Plumbing repairs or additions myself.[No workers' comp. c 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.(No workers' 13.[(Other comp.insurance required.] 'P.ny at�limntduteheoks bM err mustalso fie cat du notion below showing Neirworsess'compensation polies intotmatiaa•. t Homeowners who supmtt this afidgvlt indicating War am doing all work and the,hire outside umbamrs most submit a new affidavit indicating such. teonaletors that abeek this bas man smi had so addidmwl sheet showing the name of the subeoatraemra and their workers,coup policy information. fan an employer thor n providbig workers'compensadon insurance for my employees. Below it the policy and job site information Insurance Company Narne: TH?lCH /4'/1IE.QlON Policy#or Self-ins.Lie.#: (, U �f y 9N4 e�/4r1 Expiration Data �'Jt Job Site Address lIJ S 7- City/Stattsip:_ f Uly ho Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).' Failure to seetre coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one year impriso r=4 as well as civil penalties in Ore form of a STOP WORK ORDER and a fine of up to 525090 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 herebya under the arts and enalda o u that the information vkW above is true and correct -l•° �'.l'� F F I�Fa7 7' f Fm Siana�,,•. •atis/,".r� .._ Date: A Phone �/7!7 9?- (,89 Official use only. Do not write in this area,to be completed by city or town tifjrrciai City or Town.- Permit(Lieense# Issuing Authority(circle one): 1.Board of Health 2.Building'Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Pbane#: .. - Con%trucaan Superviior ERAIDLEYDANOFF as 1h4R121 M ROAD wdmmd FSA ofm 01131M F Unrestri - of any use nP arltioh 35, (991m3 of calor - faiute to pis a cunsent edition of the Massachusms State BWWft Cade Is camsfor revowum of this ficanse. . Far tlP5lim� vier wrvc3.RRass.Gav1[tF5 Id JtN � Office of Consumer Affaiii and Business Regulation 10 Park Plaza - Suite 5170 kv", Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 110505 Type: Supplement Card STICCA CONTRACTING CO Expka6on: 10202016 BRADLEY DANOFF 376 WASHINGTON ST _ _ __.. __ __..__. ______--.- MALDEN, MA 02148 Update Address and retoro card.Murk reason for diange. MA I a a^ssw;x I Address i ; Reoewat I Employment Lest Card I X�r Y r Mrne,-nnrwllJr r�"//r.�.rrr>Gnd/r OtRte MCommmer A6alrs 4 Bali""Ees dation License or registration valid for individal ase a* . *y Bgpauyt;MENT CONTRACTOR Ware the aspiration date. If found retara to; tt OiOa of Consumer Affairs and Business Repletion, ti�,.:yr y �Y anon: ttf 5 'Mm: 10 FM*Plaa-Suite 5176 EydraHon: iormwis SupPWI*M Card Boston,MA 62116 STICCA CONTRACTING CO BRADLEY DANOFF 376 WASHINGTON ST �..s. .._ MAt.DEN,MA 62146 Uadenw ry