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B-19-1239 - 0005 ALLEN STREET - Building Permit The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: , Buildin Official Print Name Signature Dale SECTION 1:SITE INFORMATION ' Z 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1a 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 yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Cyc", -,'-of Record: S \\ ,h � 1 Name(Print City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work 2: SA c �r K'�—`(` V 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: 2.Electrical $ ❑Standard.City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees:.$ R� 4.Mechanical (HVAC) $. List: e o.� CW 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ �j n ❑Paid in Full ❑Outstanding Balance Due: I SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) uy a�� ;C,yv-, S�,�r� License Number Expiration Date Name of CSL Holder r�so List CSL Type(see below) \�\ No.and Street Type Description Unrestricted(Buildings up to 35,000 cu.ft.) Restricted 1&2 Family Dwelling City/Town,St 21P M Masonry RC Roofing Covering � WS Window and Siding SF Solid Fuel Burning Appliances 00'i I insulation Telephone Email address D Demolition 5.21Registered Home Improvement Contractor(HIC) 1 (10%IAI-\C1 0-)- 7"a, HIC Registration Number Expuatio Date HIC CoI pany Name qr HIC Reg4gttant Name No.and Street Email address s�\k ©��o �� 1`\5=1313 -City/Town,Sta e,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 I,as Owner of the subject property,hereby authorize W % \`N !n,- V��lCr� to a o my b in 1 ers relative to work authorized by this building permit application. Print Own 's N (Electron S ature) 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. Print Owner's or Authorized Agent's Name(Electronic Signature) IDate 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 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. ov/oca Information on the Construction Supervisor License can be found at www.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 halfibaths 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" `� O�tJ•�s s t�N . I CITY OF S.LULEtii, INLkSSACHUSETTS • BUILDIING DEPnTJIENT ' 120 W ASHINGTON STREET,Ya f.00R TEL. (978) 745-9595 FAX(978) 740-9846 KIMBERLEY DRISCOLL MAYOR T Houm ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CO«fISSIONER 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 hau r) The debris will be disposed of in : G � ; s 'A� (name of facility) QO�� sz'vvvt-, (address of facility signature of permit applicant date debri%aff doc CITY OF S.,UEINr i� ASSACHUSETTS BL'II.DLNG DEPARTSCENT s 120 WASHINGTON STREET,r FLOOR T.. (978)745-9595 Put(978)740-9846 KI,%IBERLEY DRISCOLL RR MAYOR THOMAS ST.PcEB DIRECTOR OF PUBLIC PROPERTY/BUILDING CO,%5USSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 1.�,;- i -N Applicant information Please Print Leeibly Tattle(Busim-ssiOrpnization/Individual):_ Address: City/State/Zip: ��(�`t\� _ \�� Phone#: �^\�6"� S"No Are you an employer?Check the appropriate box: Type of project(required): 1. &I am a employer with� 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7• ❑Remodeling 2.❑ 1 am a sole proprietor or partner- ' ship and have no employees 'These sub=c:ontrat tiia have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. y P ry• 9. (]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] I officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑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.] •Any applicant that checks box#t must also fill out the section below showing their workers'compensation policy information. I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that cheek this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy inrotmatlon. I am an employer that is providing workers'compensation insurance for my employees Below Is the policy and fob site information. _ Insurance Company Name:___��.� Policy#or Self-ins.Lic.#: C ��`C�•1A Expiration Date: �� r 5 \\��, \ Job Site Address: � City/State/Zip—0 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 tc S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine i of up to S250.00 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 under the pains and pena111es of perjury that the information provided above is true and correct n t tr Datc: I G 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#: Your Confirmation number is 20191105363492 Date of Confirmation:11/5/2019 s' NOTE:When paying by ACH(Checking)it will take two business days for the payment to be debited from your bank account.Your account number is not verified until this payment is presented to your bank.They have the right to return this payment if unable to process this transaction against your account. Your request for payment(s)of$44.50 has been received and is subject to approval by your financial institution. No email was entered so a confirmation was not sent. Account Information Payment Information Name: WILLIAM SHEA Payment Type: C red itCard Note: QUICK PAY TRANSACTION Payer Name: WILLIAM SHEA Card Number: Transaction Information Transaction Quantity Amount Fee Payment Type City of Salem-Inspectional Services 1 $42.00 $2.50 Credit Card Building Permit First Name:william Last Name:Shea DBA/Company Name,if applicable: Name of permitted/inspected property: 5 Allen Street Address of permitted/inspected property:5 Allen Street Phone#:978-745-7313 Contact Email Address: Shearoofing@gmait.com Total:$44.50 I