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B-19-1222 - 0004 BUENA VISTA AVENUE - Building Permit 11 . : The Commonwealth of Massachusetts �A FM_i ti� 1 ® ED Board of Building Regulations and Stand s�_� FOR 014AL Massachusetts State Building Code,780 t1VIR ` � USE Building Permit Application To Construct,Repair,ReLay'a r noAsh bRevised Mar 2011 I One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: r6 5ta✓6 Cs� ,•-�f,plc -�/ /q I Building Official(Print Name) Signature D" ate ~ SECTION 1:SITE INFORMATION i ) 1.1 P operty Add+r�ss: 1 1.- 1.2 Assessors Map&Parcel Numbers V4IG A-Add W�SI 0CI O®!177 L la Is this an accepted street?yes no Map Number Parcel Number la Zoning Information: 1.4 Property Dimensions: Zoning District Propos Use L.�Y1'1 Xe . Lot Area(sq ft) Frontage.(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided ) ( 6 3oz5 35 (04 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: PublicX_ Private❑ Zone: _ Outside Flood Zone? Check if ye Municipal On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 wner'of Record: N)"gft".boo Name(Print) City,Striate,ZIP !A 6VeF°\C, ��'�[� A i�� &1-7'(/ '01( _ 1 D•�d wl 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(sA I Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify: be ec;,. Brief Description of Proposed Workz: c, �. YNI ctk� cko ctc e ; SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials y 1.Building $ I 0© 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee 100(1 ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical WAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ Voo 13 Paid in Full 13 Outstanding Balance Due: } SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder �. List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry. RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,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 I,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. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By enteri g my name ow,I hereby attest under th.pains and penalties of perjury that all of the information cont m-this ap ica on is true and accurate the best of my knowledge and understanding. 1/ I . I�i P ' t 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 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. og v/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 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. .M. 2NLxss.kCHUSETTS ' BUILDING DEPAMIENT 120 WASHINGTON STREET,31D FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KL\tBERLEY DRISCOLL NMAYOR THoMAs ST.Pmm DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMISSIONER .Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben Applicant Information Please Print Legibly Name(Busin,-'ssiOrganization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): i.❑ 1 am a employer with 4. 111 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 3.P squired.] officers have exercised their 10.0 Electrical repairs or additions 1 am a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions myself.(No workers'comp. C. 152,91(4),and we have no 12.0 Roof repairs insurance required.)t employees. [No workers' comp.insurance required.) ME]Other 'Any applicant that dm*s box#1 must also rill out the section below showing their workea'compenwion policy infumtation f 1Immowners who submit this affidavit indicating they arc doing all work and then hire oumide eontntetent must submit a new affidavit indicating such =Cwttra�tors that cheek this box must attached an additional sheet showing the name of the sub contractors and their workers'comp,policy infotrttation. 1 am an employer that Is providing workers'compensation insurance for my employees. Below Is the policy and fob site injo►madoia. Insurance Company Name: Policy#or Self-ins.Lie.fl: Expiration Date: Job Site Address: City/State/Zip: Attach it 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of . Investigations of the DIA for insurance coverage `erification. 1 do hereby r /jy and the pains and put t/es ojperJury that the 1111brotatlon provided above is true and correct: •t u Po inn�� � 30 6o O�riol use Only. Do not write in this area,to be completed by city or town opcial City or'I'own: PermittLicense# Issuing Authority(circle one): I. Board of Health 2.Building Department J.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person• Phone#• CITY OF SALEA MASSAMUSE M BLuDWG DEPARUMjgT 120 WAS1*NGTONSTREET,3RDFY.00R TEL(978)745-9595 KAMERLEYDRISCOLL FAX(978)MM46 MAYOR THMW STAERRE DIRECTOR OF PUBLICPROPERTY/BU'LD G 006"SSIOMR Construction Debris Disposal i A d ff avit re quired for al/ demolition & renovation wo rk) In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris, and the provisions of MGL c40,S54;Building Permit# —is issued with the condition that the debris resulting from this work shall be disposed of in a properly licenses waste deposit facility as defined by MGL c 111,S150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: re (name of facility) / (address�ability) � b �"/) Anature applicant r (today's date) . 4 CITY OF SALEA MASSAaiL SEM BUILDING DEPARTMENT 120 WASI- 40ON STREET,31D RDM t TEL(978)745-9595 KIMBERLEY DRISODI L FAX(978)740-9846 MAYOR 1�1O ST.PIERRE DIRECTOR OF PLBLICPROPERTY/BIAIAING 00j&uSSI0NER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: 11 � 1 ! 1 e5 JOB LOCATION_ Lt 1�7"e y`� II�i shy HOME OWNER ADDRESS: zf— PRESENT MAILING ADDRESS: S The current exemption of"Homeowners"was extended to include owner-occupied dwelnl gs of two(2)units or less acid to allow such homeowners to engage an individual for hire that does not possess a license,provided that the owner acts as supervisor. Definition of Homeowner. Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she be responsible for all such work performed under the Building Permit. The undersigned"homeowner"assumes the responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned"homeowner"cerY es that he/she understand the Cit `of Salem Building Department minimum Inspection procedures and requirements a W will comply with such ocedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPECTOR J