22 ALBION ST - BPA-16-123 NEW KITCHENS, LAUNDRY & WINDOWS $350 y
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• t-,�c��v�o .a ���,
The Commonwealth orUd •achusefts
Board of Building Regulations and Standard CITY OF
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� Massachusetts State Butldinpt(�181�M � Revised Mar 2011
M SALEM
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official U e Only
I Building Permit Number: Date Ap ied
t Building Official(Print Name) Signature Date
SECTION.1:SITE INFORMATION
1.1 Property Address: n 1.2 Assessors Map&Parcel Numbers
z 7L do3ro.J J T
1.l a Is this an accepted street?yes-AL no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Disnict Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: .. 1.8 Sewage Disposal System:
Public v- Private❑ Zone: _ Outside Flood Zone? Municipal P(On site disposal system ❑
Check ifyes
SECTION 2: PROPERTY OWNERSHIP.
2.1 Owner'of Rec
Name(Print) City,State,ZIP
;7.4 1--ea9r �a/� /3t6-�F74Z ��r��B99 �Cour s�
NoNo.and9 'relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply).
New Construction❑ Existing Building I, Owner-Occupied ❑ 1 Repairs(s)0t- Alter ation(s)A6 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': £i..7 else..✓ /tiJfcJ r��i^Jr�dWS'
n-r A Sr l oe nl / ' hrS
A-'12ay On.O / Sr ice/ ea/L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: .Official Use Only
Labor and Materials
1.Building .,Building Permit Fee:$ 21ndicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee .
00 ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ (6 Ott 2. Other Fees: $ t±
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Total All Fees: $ "
Suppression) _
Check No. Check Amount:' Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
c
MCI[ ;_zv IO1 ZS tTo j-•1I ,IZO IOtq qZ
SECTION 5: CONSTRUCTION SERVICES d"
5.1 struction Supervisor License(CSL) C.5 O 9Z797
CL �60-d-1 Z7r3L License Number Expira ion ate
Name of CSL Holder ` l
4 / _ j o� 4 ff List CSL Type(see below) y
No.and Street VZ Type Description
U Unrestricted(Buildings up to 35,000 w.ft.
R Restricted I&2 Famil Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
7915/� 75`5 — r7�� �a�/'���,t,�I y I Solid Fuel Burning Appliances
G� �/ `-"'-'r'y•/`'�% i Insulation
Telephone Email address D Demolition
5.2 Refired Home Impro ment Contractor(HIC) /0/ eO
" , �w2�f-3� AI`CCRegi,ttration Number pvation Dale
HIC CCorr2pany Name or HIC Regis m Name 78�
t o 7 f f7-:raA66,4 .0
N .a'51 tr e e1902 3(/ 4 7� Email address
City/Town,State,ZIP � O 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 ac behalf,in II t atters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Eate
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
c tried in this application is true and accurate best o y knowledge and understanding.
T�2 ( �2uaz�s� � l q L16
Print Owner's or Authorized Agent's Name(Electronic Signature) Da
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
mvw.mass.2ov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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"may be substituted for"Total Project Cost"
,�. Massachusetts -Department of Public Safety
Board ofS'u lding.Regulations and Standards
License: CS-092794w
PETER C ABBRU,ZE
24LEGGSHIlLRD'% g s
. MARBLEHEAD,MA
.,1 uv�� > Expiration:.'
Commissioner
02/03/2017
C,/
Office of Consumer Affairs&Bosiaess:Reguladoa
ME IMPROVEMENT CONTRACTOR.
l istration 149882 TYPe
xpiration 1/3 Wla: Individual
PETER ABBRUZZESE -i<
PETER ABBRUZZESE
24 LEGGS HILL ROAD'<!yy
Ij MARBLEHEAD,MA 01945 Undersecretary
i CITY OF SM. .M. 2UNSSACHUSETTS
Bt7LDLNG DEPARTMENT
' p• 120 WASHINGTON STREET,Sao FLOOR
TEL (978)745-9595
FAx(978)740-9846
1CI\iBERLEY DRISCOLL
MAYORTHOMAS ST.PtEutE
DIRECTOR OF PIBLtC PROPERTY/BuI DING CO'LLXMIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/EleetriciarWPlumbers
Applicant Information Please Print Legibly
Name(nusinssOrganizatiorvindiviiddlua_l): A-57 7AZc4
Address: l�A��
City/State/Zip: �X AJ^/ Y04 d0 Z Phone#:
Are on an employer?Chec a appropriate box: Type of project(required):
l.j4 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors ,�q
2.El am a sole proprietor or partner- listed on the attached sheet.t ?�!Remodeling
ship and have no employees These subcontractors have S. Demolition
working for me in any capacity. workers'comp.insurance. 9. Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am 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.❑Roof repairs
insurance required.]t employees.(ldo workers' 13 ❑Other
comp. insurance required.]
'Any applicant flat cwcta brat el must also rill out the section below showing their workers'taaapensanon policy nonrmad"
t I homeowners who submit this anLhvit indicating they are doing all work and then hire outside can mmot most submit a new affidavit indicating such.
=C.,one ton that cheek this box new ana^hed an additional sheet showing the name or tinsub-contnctaa and their worker'comp.policy information.
/um an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name: / t ^ �R � y/ ,�NS✓/l�✓�L O�
Policy 4 or Scit=ins Lie # i 4 A/b✓ :M0 4.3 rfJ Expiration Date:�,1/2
Job Site Address: 1 Zi f7/7DtD7'i TT City/State/zip: J�'&E.o MA ® /9?C--)
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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Oftice of
Investigations of the DIA for insurance coverage verification.
/do hereby certify a the psi s a penalties of perjury that the information provided above is true nd correct
Sicnaiure: T�J /� Data: /C0//
Phone 4: �M .l /b 7.
Official use only. Donor write in this area,to be completed by city or town ofrciai
City or Town: PermiuLicense
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#:
NOTICE NOTICE
TO d TO
m C
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I(we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
NorGUARD Insurance Company
NAME OF INSURANCE COMPANY
P.O. Box A-H, 16 S. River-Street, Wilkes-Barre, PA 18703-0020
ADDRESS OF INSURANCE COMPANY
FAWC700136 03/11/2016 03/11/2017
POLICY NUMBER 150 Sawgrass Drive EFFECTIVE DATES
PAYCHEX INSURANCE AGENCY Rochester, NY 14620 877-266-6850
NAME OF INSURANCE AGENT ADDRESS PHONE#
Fast Track Realty LLC q82 Alley St Lynn, MA 01902
EMPLOYER ADDRESS
02/25/2016
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating.physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
CITY OF S U EN1, NLLkS&ACHUSETrS
BUILDING DEPARTMENT
• 130 WASHINGTON STREET, 3m FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI1fBERLBY DRISCOLL THOMAS ST.PtERRE
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 er)
The debris will be disposed of in :
AAAjrf 'C.4� Z'6� r'
(name of facility)
ON(M£Gc,rAJ hy/�� "" D / 05'
(address of facility)
signature of permit applicant
lU� fg �ib
date
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