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BAKERS ISLAND - BUILDING INSPECTION (45) the Commonwealth of Massachusetts +I�n I' Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One-or Tivo-Family Divelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numher \S e�'S h/ln O © 1 a I.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(sy 11) 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: Public❑ Private Rl Zone: — Outside Flood Zone? Municipal El On site disposal system y� Check iryes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record:- Name(Print) City,State,ZIP No.and Street 'telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Buildinglz Owner-Occupied ❑ Repairs(s) ;4 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': Re p 103444.E A? 56rn�le 3I jk�'4 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ /7 I. Building Permit Fee: S Indicate how fee is determined: 2. Electrical $ ❑Standard Cityaown Application Fee ❑,rotal Project Cost'(Item 6)x multiplier x . Plumbing $ 2. Other Fees: $ 4 . Mechanical (IiVAC) $ List: tivt 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. _Check Amount: Cash Amount: G. Total Project Cost $ 'G�7 JfO� 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Gs i::�F} - I O61 Zy 5-7 - ,9 p/tr C�1--k v P�x 4 ,,,-5 License Number Expiration Date li Name of CSL Holder List CSL'I'ype(see below) 1Z No.and SE" {" Type Description `dam 1_`A J 1�� 19, 9 t S U Unrestricted(Buildings u to 35,000 cu.ft.)) I- R Restricted 1&2 Family Dwelling City/Town,State,YIP M Nlasonry RC Roofing Covering INS Window and Siding SF Solid Fuel Burning Appliances 37s '974/y GLn5 7S$ ,. 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) (7599� 3 -9-o?Ot8 (-4LX J1,, 'ttO�M-'M� � 1HC Registration Number Expiration Date 111C Company Name or I TIC Registrant Name 1 1p( LTCs. No.and Street Email address ���r K1k fly/s 4�g 375- S-72!Y Cit /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 ..........9 No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,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) Dare SECTION 7b: OWNEW 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. Ch ,s1ol, I1 Nc»� es Ay-a6- ao�� Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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.0ov/oca Information on the Construction Supervisor License can be found at www.ntass.,ov/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. ff.) Flabitable 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 "Total Project Square Footage" may be substituted for"Total Project Cost' !° CIz-Y OF SAILEM, lL-�SSACHUSETTS l BUILDING D EP.A RTME.NT 120 WASHIINGTON STREET, 3'e FLOOR TEL (978) 745-9595 F.kx(978) 740-9W }u\IBERLF-Y DRISCOLL VLAYOR THOMAS ST.PIE.&RS DIRECTOR OF PUBLIC PROPERTY/BUILDING CONCAISSIONER Workers' Compensation Insurance Aftidavit: Builders/Contractors/Electricians/Plumbers Applicant information �f a Please Print Legibly Name (Ilusinus Orgmiratinn'I mli victual): HD-LG'le7 1 IOrM faL NtLu.` Address: -7 Frzy er44e- 5 \. City/State/Zip: �Ge ties� O 1 9 t S Phone It: Are you in emplayer7 Check the appropriate box: 'type of project(required): I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or pan-time).• have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 2 7. Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers'comp. insurance. y. ❑ Building addition (No workers' comp. insurance 5. ❑ We are a corporation mid its rcquircJ.l officers have exercised their - 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I IF] Plumbing repairs or additions myself.[\o workers'sump. C. 152, §1(4),and we have no 12•❑ Roof repairs insurance required.) t employees. [No workers' 13,❑ Other cmnp. insurance required.) -Any apphC'JaI that ChCehB but H I mnN also fill uut the sactiun below rhowiog their workers'compensation policy inliumation. ' t I tomenwncn hvho wbmit this alrdnvit indicating they am doing all work and then hire outside contractors,most suhma a new afQdavit indicating such. :( 'ant m. ton ihul chak this box most anochmr un addiiiinse sheet showing he mmtic of the subauntracton and their workers'comp.pulicy information. f unt on emptuyer that Is providing workers'compensation insurance for my employees. Heloly is the policy and fob sloe iofurneation. Insurance Company Nane:Policy d or Sclr-inn. Lie. d: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). F'ailuru to scrum coverage as required under Section 23A ot'MGL c. 152 can lead to the imposition oferiminal penalties of fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and it line OF up to S250.00 a Jay against the violator. Be advised that a copy of this statement may be Forwarded to the Office of I nvcsi igut ions ofthe DIA For insurance coverage veri licalion. /do hereby rertif raider are pains and pen (ties of eriury that the inforntution provided above is true aad correct. Phone i cl 7f_ 37T 9 7°/!Y [0) use rally. Da"of'write in this area, tube completed by city or town ofpcial orAtithurily(circle one):of Ilealth 2. Building Department J.Ciiyfrown Clerk 4. Electrical inspector 5. Plumbing In.vpecror Person:_ Phone ,Y: CITY IUE�bOF 2 �ti -kS&: CHUSETTS BL'ILDLYG DEPARTMENT 130 WASHNGTON STaEET, JW FLOGR [ iL (973) 745-9595 MAIDERLEY DRISCOLL FAX(978) TW-9844 N LA YO it -r,-iOb LAS ST.PnE,RItg DIRECTOR OF PUBLIC PROP ERTY/HC'tLOLNG COtLtpg�IO�EZ Construction Debris Disposal AftIdavit (required for all demolition and renuvation work) In accordance with the sixth edition ofthe State Building Coda, 730 CD.IR section l l I.S Debris, and the provisions of,blGL c 40, S 54; Building Permit 4 is issued with the condition that the debris resulting from this work shall be dispascd of in l 11, S ISQA. a properly licensed waste disposal facility as defined by rmGL c The debris will be transported by: y r� (n.,mc ufhaulcr) The tlehris will he disposed ot,in ' � (:,,Idress Yrimility) b pamit applicant n l.� t