10 BELLEVIEW AVE - BUILDING INSPECTION (2) IL
The Comnsonwcalth of Massachusctis Town of
Board of Budding Regulations and Standards
Massachusetts State Budding Code, 780 CMR. T"edition imenow
Building Dept
/ Building Permit Application To Construct, Repair, Renovate Or Demolish a �
t_
One.or ruo•Pwrufs'Du offing
This Section For Official Use Only
Building Permit Number Date Applied:
Signature:
Budding Commissioned Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Properl ddreas: 1.2 Assessors Map 3 Parcel Numbers
1.1&Is this an accepted street'?yes no Map Number Parcel Number
LJ Zoning Information: 1.4 Property lmensions: �O
CEJ -5-?J00
Zoning District Proposed Use Lot Arca Isq N Frontage(Msystem
13 Building Setbacks(II)
Front Yard Side Yards Re
Required Provided Required Provided Required
1.6 Water Supply:(M.G.L c.e0.f Sa) 1.7 Flood Zone Information: 1.8 Sewage Dbpo
Zone: _ Outside Flood Zone? Munieipel� On sit
Public IA Private O Check it s0
SECTION 2: PROPERTY OWNERSHIP' �,l
2.1 O n r'ofRecall ✓/�%�+�7 ✓�S
Name(Print) e� Address 7«
-7 : 7�j - "6'
r/ 6 /
Siptature Telephone /(¢
SECTION J: DESCRIPTION OF PROPOSED WORK'(check a8 that apply)
New Construction O Existing Building Owner-Occupied Repairs(s) O 1 Alterations) Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Pro sed Work': V
7MCMLG b
T'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: ORIela1 Use Only
Item Labor and Materials
I. Building f ODC� I. Building Permit Fee: f Indican how fee is determined:
O Standard CityrTown Application Fee
2 Electrical S 090 O Total Project Cost'(Item 6)x multiplier �] \
) Plumbing f / �'QD 2. Other Fees: S �-�
i. Mechanical (HVAC) f List: �l� 11V//v✓v/
I Mechanical (Fire f Total All Fees: S
Su remora
Check No. _Check Amount: Cash Amount:_
h Total Project Cost f A?)Od d ❑Pad in Full ❑Outstanding Balance Due
°mat-d A
j r
SECTIONS: CONSTRUCTION SERVICES
3.1 Licensed Construcilon Supervisor(CSL)
•l L �n(�f�s License Number EspirilionDute
.vyae til('SL IIpIJet,
► s G - ��n �— Led CSL type Ixe ti
Address i
ID
UnrestnRestricted l R2 FamilDwelh$raniiiNa ResrdemTelephone ResidentialResrdenuResidential Demolition
3.2 Istered Home Impro7rnyI Conerv�/1ctor(NIC)
QJ
/-Ias
HIC CName or HIC Registrant Name Registration Number
5m -�bvn �o� ryr� - 3/- 2oi/
Adrlfe
Expiration Date
Signanrm Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISI;.f ISC(6))
War'
en 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? Yea.......... No...........0
rSignmum
a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
e.'(*k- �^� as Owner of the subject property hereby
2 f.ST b ✓�arm /�i f'J to act on my behalf,in all matters
rk authorized by this building permit application.
ner Get
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, A Y)v, 44z_ 11,
(,UC ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
3 ZYi f(3
Signature of Owner or Authorized Agent Date
Sr ned under the pains and penalties ofperjury)
Noyes:
1. An Owner who obtains a building permit to do hiAer own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program).will do have access to the arbitration
program or guaranty fund under M.G L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110 R3,respectively.
2. When substantial work is planned,provide the information below
Total floors area(Sq. Ft.) (including garage, finished basemenbanics,decks or porch)
Gross living area(Set. Ft.) Habitable room count
,Number of fireplaces Vumber of bedrooms
Number of bathrooms Number of half baths
Tvpe of heating system Number of decks/porches
Ti,pe of cooling system Enclosed Open
1 "Total Project $quare Footage'may he suhsntuled for 'Total Project Co%i'
l
CITY OF SALEM
• PUBLIC PROPRERTY
DEPARTMENT
tl
\I J"H IlO IX.VIII\I.;,INS OtLCT ♦SAI I'\I,
IF1:'178.743-7395 •1'.%x;979.7449846
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with cite sixth edition of the State Building Code, 730 CMR section I 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I It. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(nartle utTact
uy) ex-(
(:IIIIIrCSS III facility)
+ignawre of permit applicant
(late
;i
1 \
iNlassachusetts - Department of Public Safetc
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 76488
Restricted.to: 00
CHRISTOPHER S ANNIS
5SEABURY
HAMPTON, NH 03842
? •Y x,
Expiration: 1/31/2012
t tmmi.xinne r. Tr#: 14031
0/ � �>
�\ Office of Consumer Affairs& usiness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration:7',`3112011
Expiration: 7/31/2011 Tr# 266716
Type-
CHRISTOPHER"S ANNIS Ti
CHRISTOPHER ANNIS n
5 SEABURY
HAMPTON,NH 03842-; Undersecretary
64' CITY OF S.1 .&M. %L%ss.tcHt:sEM
BL'LLDING DEPART IUNT
120 WASHINGTON STREET, )'e FLOOR
TEL (978) 745-9595
F.tx(978) 7.10.98x6
pNCBER FY DRISCOLL
HAYOR T2omu ST.Pmman
DIRECTOR OP PL'ELIC PROPERTY/MCI DLNG COMNBSS20NER
Workers' Compensation Insurance AMdavit: Builders/Contracton/ElectrlclanslPlumben
Anolicant Information Please Print Legibly
Valnd7lauai'sesa,Orgwtrniott.Ittdavrduall: �f�Tl1�%�i�l_--'/L J'`�/�Cs�( J S
Address: Sea b v.7
City/State/Zip: `" /',-( Phone*: (e b2—Z,3 -�7zJB
Are you as emplayer!Cbeek the appropriate box:
1. 0 1 am a Type of project(requlydtd!}
1.� 1 am a employs with grnctal contractor and 1
ern to part-time)." have hired elle srb•contractors 6. 0 Now construction
P,)�lhrtl and/or art-tuns).
2.91 ams sole proprietor or partner. listed on the attached*heel,: 7. Remakling
,hip and have no employers Thee sub-,contractors have 8. 0 molition
working for me in any capacity. workers'Comp.irnluaoM 9. 0 Building addition
lNo warkers'comp. insurance S. 0 We are a corporation and its
ruquiraL) ot7lcas have exercised their 10.0 Electrical repairs or additions
J.0 1 am a homeowner doing all wort right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'Comp, C. 172,41(4),and we have no 12.0 Roof repairs
insurance required.)► cenpbylecs.LNo workers' 13.0 other
—
;Any
insurance required.)
-Any appatad the tbacaa baa e1 MMM AW fill out the Ionian bdow abowing t6dr walka'tatttpwdaad,w polity in ii nurba.
'I bwwuwnm who subsul Ah sdldavk indiodns May ata doing all task and thea him ousile tatuaI t want*anorak a naw arxttsvil ked thea y rue►.
T.wtmtam that cWtk ibis boxtaw anashnd an add inowl ahwt showing dM Daae o/Iba Ads raeous"a"theleworkam'req•policy iatnmrnaaw
/oar an v rbar tr pnridtnr Iswrbers'canrpwnsaden tee/a"scauv any eaplrtyerar S111901'S111901'Is rAi)PIll red Jot slit
information.
. ,
Insurance Company Name:
Policy M lir Self ins. Lie.p Expiration Date:
Job Site Addicts: City/State/Zip:
Attack a copy of The workers'compensation popsy declmd@n pap(akewing the polley camber and explradon daft).
Failure to wxura coverap as required under Section 25A of NGL C. 152 Can lead to the imposition of criminal penalties of
fine up to S1,500.00 and/or one-year imprisonment,err wall u civil penalties is the form of s STOP WORK ORDER and a Bae
Of up to 5250.00 a day against the violator, lie advistxl that a copy of this statament nuy be forwarded to the 0171ce of
Invebligaliuns.delta DIA for insurance coverage verification.
/da hereby es,n!/y n r r psi rad yang/Her o/perjury that Ike injairmadon araridd above is rrur and armed
auto
PNInca• ��b �S /Y�f' /t
(J/Jtcia/use dalA Or 1001 write in rhia ager,if br.uenp/rtd by airy V rows a/Jtci d
_
City or ruwa:
- Pcrmit/Llccnre N—_
i
Nsuing.whurity (circle line):
I. Ituard of Iltallh 2. Ruilding Department J. City/rows Clerk 1. Electrical Inspector 5. Plumbing Inspector
6. 01 her
L.,ntacl Person: _ ._ _.. Phone c