17 CEDARCREST AVENUE - BUILDING JACKET . t
'� 12- $ Ckc2�q INSPECTIONAL RECEIVED
The Commonwealth of Massachusetts
r 1.. Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised.Mnr 20/l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fancily Dwelling
This Section Fur Offtei I Use Only
Building Permit Number: Dat Applied:
Building Official(Print Name) Signature Date
SECTION l:SITE INFORMATION
1.1 Pro ert Address: 1.2 Assessors Ma & Parcel Numbers
11 cow Cnl� p
].to Is this an accepted street?yes x no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use For Area(sq fl) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards (tear 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❑ Private❑ — Municipal❑ On site disposal system [ICheck ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofRecord: AIexei Grishln IS
Name(Print) City,State,ZIP
17 Cedarcrest Ave 781 -605-8276 Deses@inrebUS.c0m
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction tK Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition Cl
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Workzl:
VrI�V n 1-1-Q1 C. So0.r Sy S-FPYYIS
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:
2. Electrical $�y ..00R ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No._Check Amount: Cash Amount:
r� _
6.Total Project Cost: $ ,C,606 A7jO 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1- by-525L4 a 2g 19
-!ict- e-s f Y,he- ' Yvan License Number ExpirationDae,
Name of CSL Flolder
IR 1 I-ka�In List CSI..'I ype(see below) U
No.and Street 'type Description
Sc - t,-S i p I k ��C )L U RestrictdUnrestricted(Buildings2 Fm u el in O(10 cu.fl.
��l R Restricted I&2 Family Dwelling
City/Town,S t• ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
_ SF Solid Fuel Burning Appliances
`1si-6 L6 YVIG15U1QYpVlutVbi fti, I Insulation
Tele hone Email address rn D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
11/LVII So`� Dave 1ope l �C i io5s 18 _J5�lµ
HIC Registration Number Ekkpiration Date
14�3npzt�Nzt�OD HIC_ Rggis[ranl Names JJ
I W YV�,aSOILu'QVLVIt'lA-So) ir.
No.and Street Email address CArvt
Provo La $t}(oo4 -I%13D5301aS
City/Frown,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..........A No...........❑
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize VI V 11t St)lar-
to act on my behalf,in all matters relative to work authorized by this building permit application.
/Jlob l G tp t�� 10/8/14
Print Owner's Name(Electronic 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 is I i pl lion is true and accurate to the best of my knowledge and understanding.
LC)I�
Print Chvt s r rized 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 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 www.mass.eov/tins
2. When substantial work is planned,provide the information below:
Total floor area(sq.R.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq,ff.) 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 systan Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
vownt solar
4931 North 3011 Nest
Structural Group Provo,UT84604
P: (801)234-7050
Scott E. Wyssling, PE
Head of Structural Engineering scott.wysslingCa vivintso lar.com
October 18, 2014
Mr. Dan Rock, Project Manager
Vivint Solar
24 Normac Road
Woburn MA 01801
Re: Structural Engineering Services
Grishin Residence
17 Cedarcrest Avenue, Salem MA
S-4002515
5.1 kW System
Dear Mr. Rock:
Pursuant to your request, we have reviewed the following information regarding solar panel installation on the roof
of the above referenced home:
1. Site Visit/Verification Form prepared by a Vivint Solar representative identifying specific site information
including size and spacing of rafters for the existing roof structure.
2. Design drawings of the proposed system including a site plan, roof plan and connection details for the
solar panels. This information was prepared by the Design Group and will be utilized for approval and
construction of the proposed system.
3. Photovoltaic Rooftop Solar System Permit Submittal identifying design parameters for the solar system.
4. Photographs of the interior and exterior of the roof system identifying existing structural members and
their conditions.
Based on the above information we have evaluated the structural capacity of the existing roof system to support
the additional loads imposed by the solar panels and have the following comments related to our review and
evaluation:
Description of Residence:
The existing residence is typical wood framing construction with the roof system consisting of 2 x 6 dimensional
lumber at 24" on center. Collar ties were not present during the inspection. The attic space is unfinished and
photos indicate that there was free access to visually inspect the size and condition of the roof rafters. All wood
material utilized for the roof system is assumed to be Spruce-Pine-Fir #2 or better with standard construction
components. Our review of the photos of the exterior roof does not indicate any signs of settlement or
misalignment caused by overstressed underlying members.
Stability Evaluation:
A. Wind Uplift Loading
1. Refer to attached Ecolibrium Solar calculations sheet for ASCE/SEI 7-10 Minimum Design Loads for
Buildings and other Structures, wind speed of 100 mph based on Exposure Category "B" and 19, 36 and
11 degree roof slopes on the dwelling areas. Ground snow load is 40 PSF for Exposure "B", Zone 2 per
(ASCE/SEI 7-10).
2. Total area subject to wind uplift is calculated for the Interior, Edge and Corner Zones of the dwelling.
bodont. solar
Page 2 of 2
B. Loading Criteria
10 PSF=Dead Load roofing/framing 40 PSF= Live Load (ground snow load)
5 PSF= Dead Load solar panels/mounting hardware
Total Dead Load=15 PSF
The above values are within acceptable limits of recognized industry standards for similar structures. Analysis
performed of the existing roof structure utilizing the above loading criteria indicates that the existing rafters will
support the additional panel loading without damage, if installed correctly.
C. Roof Structure Capacity
1. The photographs provided of the attic space and roof rafters show that the framing is in good condition
with no visible signs of damage caused by prior overstressing.
D. Solar Panel Anchorage
1. The solar panels shall be mounted in accordance with the most recent "Ecolibrium Solar Installation
Manual', which can be found on the Ecolibrium Solar website (ecolibriumsolar.com). If during solar panel
installation, the roof framing members appear unstable, deteriorated, structurally compromised or deflect
non-uniformly, our office should be notified before proceeding with the installation.
2. Maximum allowable pullout per lag screw is 235 Ibs/inch of penetration as identified in the National Design
Standards (NDS) of timber construction specifications for Hem-Fir (North Lumber) assumed. Based on
our evaluation, the pullout value, utilizing a penetration depth of 2 1/2", is less than what is allowable per
connection and therefore is adequate. Based on the variable factors for the existing roof framing and
installation tolerances, using a thread depth of 2 '/z' with a minimum size of 5/16" lag screw per
attachment point for panel anchor mounts should be adequate with a sufficient factor of safety.
3. Considering the roof slopes, the size, spacing, condition of roof, the panel supports shall be placed at and
attached to no greater than every other roof rafter as panels are installed perpendicular across rafters and
no greater than the panel length when installed parallel to the rafters (portrait). No panel supports spacing
shall be greater than two (2) rafter spaces or 48"o/c, whichever is less.
4. Panel supports connections shall be staggered to distribute load to adjacent rafters.
Based on the above evaluation, it is the opinion of this office that with appropriate panel anchors being utilized the
roof system will adequately support the additional loading imposed by the solar panels. This evaluation is based on
information supplied to us at the time of this report and current industry standards and practices.
Should you have any questions regarding the above or if you require further information do not hesitate to contact me.
ery truly yours,10
11
o E
1
Scott E. WY ling, P I,�;yvoS50 y
MA License No. >• e
F 90F P G157E
ESS/ONM-
dabunt. solar
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No .
I 17 Cedarcrest Ave, Salem MA 01970 I (1) a
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PV INTERCONNECTION DISCONNECT
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LOCKABLE DISCONNECT SWITCH,
ANSI METER LOCATION,
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20)Yingli Energy YL255-29h MODULES WITH A U 3
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MOUNTED ON THE BACK OF EACH MODULE I ? ? f o
SHEET
NAME:
JUNCTION BOX ATTACHEDTJ I w Z
ARRAY USING ECO HARDWARE TO . J
KEEP JUNCTION BOX OFF ROOF (n a
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NUMBER:
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Roof Azimuth:167
Roof Tilt:19
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Roof Section 2 Roof Section 3
RoofAzimuh:167 Rod Azimuth:167
Roof Tilt 36 Roof TR 36
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RoofAnmuth:167 16 MODULES w w U
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NUMBER:
PV SYSTEM ROOF PLAN 4
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SEALING421/2'
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EPV MODULES, TYP. MOUNT �OF COMP SHINGLE ROOF, FLASHING (nPARALLEL TO ROOF PLANE MIN (76116"0 x 4 1/2"MINIMUM STAINLESSN.
PV ARRAY TYP. ELEVATION STEEL LAG SCREW
NOT TO SCALE TORQUE=1332 ft-Ibs 0
CLAMP ATTACHMENT (n
NOT TO SCALE
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CLAMP+ m
ATTACHMENT CANTELEVER U4 OR LESS
COUPLING J
L=PERMITTED CLAMP VVV
ECO SPACING SEE CODE COMPLIANT
COMPATIBLE LETTER FOR MAX ALLOWABLE
MODULE CLAMP SPACING. g '"
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p p N
PERMITTED COUPLING 5 W o
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COUPLING PHOTOVOLTAIC MODULE
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NAME:
L=PORTRAIT y
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COMPATIBLE SHEET
L=LANDSCAPE MODULE PV SYSTEM MOUNTING DETAIL NUMBER:
CLAMP SPACING
MODULES IN PORTRAIT/LANDSCAPE NOT TO SCALE 1 M
NOT TO SCALE
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Inverter Ratings(Guide Section 4) Q Conduit and Conductor Schedule
MODULE DETAIL mpemor Mabpleosel Enphase M21s6o-z11-Sex-zc Tag oaropron ware Gaga .1 Cramomem Condwt Type Coral Sea
Max GC Volt Rating 451 Vols
Max Power @400C 2151 Watts 1 Eapham engage arbl•-THWN-2 12 AWC' 4 CON NIA-Fee Alr o'
Nominal AC Voltage 2401 Volta 1 Be.Copper Ground(EGGGEC) 6AWG I WA Free Air NIA-Free As „ o
YIni Energy YL255-29b Max AC Cunent n9 Amps 2 THvi 10AWG 6 WC 0'-1.
SOLAR MODULE Max OCPD Rating 20 Amps ^` op
Max Number of Pyramidical 17 2 THWN-2-Ground 8AWG 1 M W
C 0'-1' o
3 THWN-2 8AWG 3 MC 0'-1' ypm
NOTES FOR INVERTER CIRCUIT S(Guide Section 8 and 9): BAWG PVC 0'-1' •NQom
3 THWN-2-Groune t
1.)IF UTILITY REQUIRES A VISIBLE-BREAK SWITCH,DOES THIS PV Module Ratings @ Si(Guide Section 5)
m u
Enphase M215E0-2LL-S2x-ZC SWITCH MEET THE REQUIREMENTS? z
MICRO-INVERTER AT YES NO XNA Modal oppositional Yingli Energy YL25S29b -t_
EACH MODULE,ATTACHED Max PowerPotm Cement(imp) 8.32 Amps Uvj
2.)IF GENERATION METER REQUIRED,DOES TH IS METER Max PowerPant Voltage pi 30.6 VDlts I•r MO
WITH ECO HARDWARE SOCKET MEETTHE REQUIREMENTS? OpenCimuil Volrage(Voc) 3i1.7 Volts �'ma
YES NO XNA ShonCircuit Cement flat) 8.06 Amps 4
3.)SIZE PHOTOVOLTAIC POWER SOURCE(DC)CONDUCTORS Max Senes Fuse(01 15 Amps, •L
BASED ON MAX CURRENT ON NEC 690.53 SIGN OR OCPD Nominal Maximum Power at STB(Pnax) 255 Watts
MICROINVERTER CONNECTION _—_ RATING AT DISCONNECT. Maximum System Voltage 1608(IECyfi08(Uy
TO ENGAGE TRUNK CABLE 4.)SIZE INVERTER OUTPUT(AC)CONDUCTORS ACCORDING Voc Temperature Coefficient d]2 %PC
^ TO INVERTER OCPD AMPERE RATING(Sao Guide Section 9).
V 5.)TOTAL OF 2 INVERTER OCPD(s).ONE FOR EACH NOTES FOR ARRAY CIRCUIT WIRING(Guide Section 6 and 8 and Appendix Of:
PV CIRCUIT.DOES TOTAL SUPPLY BREAKERS COMPLY Law
WITH 120%BUSBAR EXCEPTION IN 1.)Lowest expected ambient temperature based on ASHRAE minimum mean extreme#6 BARE CU GROUND �r6
NEC 690.64(B)(2)(a)? XYES NO dry bulb temperature for ASHRAE location most similar to'mstellation locatio V
n: .19•C �I 1
(GROUNDING ARRAY) Signs(See Guide Section 7) 2.)Highest continuous ambient temperature based on ASHRAE highest month 2%dry bulb a•"'
bandannas for ASHRAE location most similar to Installation location: 39-C
Sign for inverter OCPD and AC Disconni 3.)2005 ASHRAE fundamentals 2%design temperatures do not exceed 47-C in the
United States(Palm Springs,CA is 44.1°C).For less than 9 cument-carrying conductors
Solar PV System AC Point of Connection in roof-mounted sunlit emndue at least as alma,met and using the outdoor design
AC ONpe Cunent Is 0000011 Amps temperature of 47•C or less(all of United States).
Nominal AC Voltage 240 Volts at 12 AWG,90•C conductors are generally acceptable for modules with lac of]68 Amps � <
or less when protected by a 12-Amp or smaller fuse. ry
THIS PANEL FED BY MULTIPLE SOURCES
(UTILITY AND SOLAR) b.)10 AWG,90-C conductors are generally acceptable for modules wiN lac of 9.6 Amps at
or less when pratectedb a 1 5-Amp or smaller fuse.
NOTE:NEUTRAL CONDUCTOR(S)OMITTED FOR CLARITY o
ALL INVERTER OUTPUT CIRCUITS WILL HAVE A NEUTRAL CONDUCTOR
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at
PV CIRCUIT 1: 16 MODULES/PARALLEL ENVOY BOX 'r m N
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,6 • • • O p onIT „ <
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MURRAY POINT OF DELIVERY tu of
COMBINER AND INTERCONNECTION � w ?
EL 125A/240V SIEMENS r r 4 ;
\G GLWO04NR 60A1240V rn w
1 ON OR EQUIVALENT UNFUSED NEMA3 M z MID
1 O\t(` C LNF222R OR SHEET
PV CIRCUIT 2: 4 MODULES/PARALLEL \\, SREC/ANSI EQUIVALENT NAMEOF` METEREXISTING
aD240V/200A ZzoA LOAD-CENTER �15AM 35P SHEET
NUMBER:
___ ______
JUNCTION BOX \\ MILBANK VISIBLE/LOCKABLE �_ p
ANN, \\ 3 100A OR 3 'KNIFE'AIC 3 Ni
NEC 2014 Compliant WITH IRREVERSIBLE E 1 0 \ EQUIVALENT DISCONNECT
GROUND SPLICE \ E 1.0 U5934-XL-BLG E 1.0 E 1.0 LLI
1 , I
The Commonwealth of tMassachuselts
] � Board of Building Regulations and Standards LRevised
F
li( Massachusetts State Building Code, 730 CYIR SALt1U/1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Sect(oti For Official Use Only.
Building Permit Number. 1 Da '
t, 7 .7 ./3 .
Building Official(Print Nor e) $tgnalur Date
SECTION I:SITE INFO HATION
IA Property Ad.dress: /�// /J/ J / 1.2 Assessors Map& Parcel Numbers
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 Q) Frontage(ft)
1.5 Building Setbacla(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zane? Municipal❑ On site disposal s ❑
Check if es❑ stem p P Y
ACTION!; PROPERT1d'OW(VERSHIP!
2.1 Owner:of RocordVQP
Name(Print) C�i�y.State,Z�IP17 rzri/ r�
�76 /9lIJ
No.and Street Telephone Email Address
SECTION J: DESCRIPTION OE PROPOSED WORW'6heck all that apply)
New Construction❑ Existing Building C t Owner-Occupied ClRepairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work":
erl lo�i� fry -F� an V'GD 4:G
ih (tl5yoS r vr� �iarL'
SECTION 4: ESTILNLAfED CONSTRUCTION COSTS-
Estimated Co",*- OlBda) Use Only..
Labor ind Xraterials Y' ..
1. Building g 1. Building PermitFee:3 Indicate haw fee is determined:
a. Flectriad S !?Slandacd.City(rown,Application Fee,
Q futat Project Cost(Item 6)x multiplier x
1. ! lambing i ?- Other Fees .S �(
t ,Mechanical (IIVAC) i List:_ ��Il
�. .\ledt.mic.d (Pin:
Ibt.tl A11 Pees:i
far Chad No. Chcc!c I\uwnut: (',c;h :\uwimt
_---
l� I .iil in Fall _ _,❑Otlktatiding 11:11,ate.: Una:
• r ,
SlEcrlON 5: Co;N57RUCl'ION SEiMCES
5.1 Construction Supervisor License(CSL) ��� _ 56�
All ���/� _ License Number Gepir:`tiuu Uane
Name of CSL I luldur p` List CSL type(sue below)
62n?IAI/ /fie — Type Descriptiun
lo,)tnd Stmet U Unrestricted 0uildin 0 up to 35,000 cu. tt.
It Rustricted l�?F;unil DwJllin
1�l if
City/ro\vn.State,GIP Rout nr
RC Ruutin Cuverin
WS Window andSidin
l SF Solid Fuel Elurning Appliances
t mdUdli�(�n�Aarz�,r1.< I Insulation
Pula hung
Email address D Demolition
5.2 gl for d mnt Improvement Contractor(HIC)
HIC—Registration Number E.epuntiion Date
I I I C�Jmpayt� yt _ur I R st u N na M�, r ,i��yp�OM+Ge ✓`��rr
66 fCf �r� 1 �, i ,
c7`�5et
Email address
Ci /Town Stat 'LIP Tale hone
SECTION 6: WORKERS'colvIPENSAT[ON INSURANCE AFFIDAVIT(N(.G.L.c. 152. 9 25C(6))
Worken Counpensatien 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 7s:OWNE AUTHORIZATION TO DE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize �✓ �!v
to ton my behalf, in all matters relative to work authorized by this building permit up lication.
ar>o j 6 3
Date
Print Uwner9 Name(Electronic Ignature)
SECTION 7h: 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 understan�di�n�g.
61b�i3
I•flln L)\YIIJ('3 Jf Audwrwe7:\�s NJme(Eluctrunrc�Ignautre)
Date
NOTES:
I. owner who hi
:\n Owner who obtains.11)
uilding permit to do hivher own work,ur an hires In unregistered contractor
(nut registered in the Florae Improvement Contractor(HIC) Program), will no have access to the arbitration
program or guaranty tend under M.G.L. c. la?A. Other important information on the HIC Program can be round at
\1\y IV.111lt;; t:uy%at;tirts4 +:uv%ar;t Infonnatiun un the lbnstrutaion Supervisor l.icunse uan ba round:u\\\vw.nrus. �I)
> When sub.-iit \York is planned•provide the information belwv:
I'utaltluorarcu(;\l. lt.) _ _(including,:uage, 6nishedbaselneatiattics,decksurPorch)
H.i
iI living area('iy. It.) __ ber room count
_
`fumhentfbcdrulnn; _-_--_--
?hunbcroflirapla\x, ....... _.--. -- Nmuherothaltbaths -.
\luutbcr of h.uhrnlnn; ----------
� I}he ,Ifh:.uinl; ;y<icnt - -- --- ?:nmbcrnt�kcl;' I'urih<+ --- --
Fucla:cd ---- Ipco
j a "I-.�111 IY„L•�.t � pl in: I ,t r;c' ul.ly he aih,nnil:,I I,a .. Im.11 ,t"
I'lie Cbnmuomvealih of M:ssachusclts
r 'a Board of Building Regulations and Standards Cl F), OF
VLtssaduusells State Building Code, 7SO C NIR
Ya Il' 'L"•, Reri.,.'i1.16tr all l
I Building Permit Applicuhill To Construct. Repair, Renovate Or De 'sh a
One-or rnv-Fiends'UnYlliu,p
This Section For 011icial Ure Orel �
Building Permit Number: Dal li• ,
Iluilding 011icial(Print N+une) Signs ure Uate
SECTION 1:SITE INFOR31ATION
I.I Property�Address: p 1.2 Assessors Slap S Parcel Numbers
i1 1 k-,e r Cn.Cf'C t A\f k
1 �
.la Is this an acce led street? 'es ✓ rio Map Number Purcel Ntunt,
1.3 Zoning Information: 1.4 Property Dimensions:
Io11111g District 1'nrpured lire but Area(sq II) Fn-11 (II)
1.5 Building Setbacks(B)
Frum Yard Side Yards Rear Yard
Required Pruvidud Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.Jo,§54) 1.7 Flood lone Information: 1.3 Sewage Disposal System:
Public Priv ate❑ Zone: — Outside Flood Zone?
Check if aC Municipal❑ On sits disposal r)rtem ❑
SECTION3. PROPERTYOWNER-----
2.1 Owners of Ree�Q:
�l �P 4�Af17Pf Q �1�1•P�n
N:one l Pnaq - Clq,Slate.All
78 ASS@� 5 978-335 15-50*01'
Nu.:u1J Street ' relephone klnail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ E.risliny Building Owner-Occupied ❑ I Repairs(II) Alleratlon(s) Addition (3
Dentolition ❑ Accessory Bldy.❑ Number of Units_ Other Cl .Speedy:
Brief Description of Proposed Work': >�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
licill Estimated Costs:
(Labur;md.\laterials) Ofllclul Use Only
1. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Hv,;Irical S ❑Standard CitpTown Applicuion Fee
7. I'lun hing S ❑Total Project C'ostl l liens 6)r multiplier -
_. Other Fees: S-
J. \Ie�haniial ill% W) 5 List:
S IVIrc\Iech.miral _ --
F +/e�riunl S rotal \11 Fce$: S
6 Total I'rnjcct Cost: ,,��-- ('heck No. _.. __(heck Anl,nan: . _._..-..C•i�h \ni.....
�viCxr�t� ❑r,dd in Full 0 Outslanding Hal,ulce Doc:
SF:("I'll)N S: ('ON51'RU!"flON SF.RVI('F.S , ,
5.1 C'onstruclion Supen'isor Licensr(CSL)
I Ieen,e Nunlher P\ int ou I Ile
h .
Min LA. .. . ---
Name of C'SL I Ildcr,^�, I Ist CSI. I)pu
2 l(('`Y � - T _. —_.__-_.___ h)Pe Description
N,I. mid Strecl (I IhtrcslrieleJ llLulJin'y ti l014,111111 eu. 11.1
It I(cmrmted Ice'? f.nnil I)++ullin
.1 \I !Mason
l'igi I'o++n,Slate./.II'
RC HtnJin Co\crin
W'S W'indow,Ind Sidi,
SF .'Solid Fuel Iluming Appliances
Insulation
r/LLl[ _1v Flinaiill add Y� D Demolition
lblc hmw
S3 Registered Ilume Improvement Contractor(HIQ 1 -t0 /
Itegislr li�n Nwulkr li pir line Uule
I IIC 'oI n) N,une or IIIC It.glatrun Nanla 5�C)? Email address
m1J Sleet j I) O G�!
f
Ci /Town.State ZIP fete hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 192.1 35C(Q
Failure to provide
Workers Compensation Insurance affidavit must be completed and submitted with this application.
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No•• O
SECTION 7a: OWNER AUTHOIUZATION TO BE C0111PLETED WNEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,In all matters relative to work authorized be Is building permit application.
�� I/ G�1 i✓ QCi�- a.(/—/)—
/nth ��( P�^r7 t2d Data
PnI1t Owner's Nwne(LIMMnle Slgnulum)
SECTION 7b:OTVIll OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
eoatai d in this application ' true and accurate to the best of my knowledge and understanding. /a
/JA��(�YIVLJJIL Dato
I'riut U\\n• s ur:\uthonnJ \µat s Nnn1e I IJutr •Sig nurn)
NOTES:
1. .\n Owner who obtains a building permit to do his her own stork•or an owner who hires an unregistered contractor
( lut registered in the Hume Improvement Contractor I HICI Program).will LUJ have access to the arbitration
program or guar;ulsy fund under M.G.L.c. la_'A. Other important information on the HIC Program can be found at
n,L. " • I Information on the Construction Supervisor License can be found at2.
\\hen substantial ork is planned, provide the infunnation below:
foie! ,lour area t ni w I including garage. finished basement attics,decks or po"h l
hlabitable room count
Cross Ii\ing .lrealsy. 11.1 ..---. -... \uulher Lit hedroonls
\unlheroFtinplaas .. .. —_ \untbcrof'ilall h;uhs . . . .
\gnnherotbathrvoms \tlIIlherUfdeek)• porclta
I pc of healing i):teln
I'ncla,cJ
I I,e of eooh 1g i\ticlll
.. I
i
1 "I'.dJl Proled SIIIIIIre 1:00I.WC 111;11 he NIbH11111cd Ilrt"I ULII 'rajeCl('osf•
i •