34 BELLEVIEW AVE - BUILDING INSPECTION (4) 7 C, zS(o S
The Commonwealth of Massachusetts w;PE IOHAL 5 RVOS
Board of Building Regulations and Standards '
CITY OF
" EM
Massachusetts State Building Code,780 CM �b NAY ¢ fWMar 2 011
v
Building Permit Application To Construct, Repair,Renovate Or Demolish a
T One-or Two-Family Dwelling
This Section For Oflicial,Use Only
Building Permit plumber: °' Date Applied:' _, '
Building Official(Print Name) .<'. ,;Signature a 'Date s
'$ECTIONI.SITE INFORMATION_
1.1 PropertyltV
eddress: S 1.2 Assessors Map&Parcel Numbers
L I 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(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yazd 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 El On site disposal system ❑
Check if yes❑ ,
SECTION 2 PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Kt„VF 3'1 B�/rLr.,'r tri j1 v�
Name(Print) City,State,ZIP
'?treet J3CIlLvi�✓ 61741177V mkcinc-4±2q�2o�/r�7 %(
No.and S Telephone Email Address
SECTION 3:.DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ `Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of ProposedWorV: v�
�✓ nW fri�:le44 4
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only ,
(Labor and Materials
1.Building $ ?� Co 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ SdU ❑Standard. City/Town,Application,Fee }
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 'l UO 2. Other Fees: $ -
4.Mechanical (HVAC) $ :List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No: Cheek Amount: Cash Amount:
6.Total Project Cost: $ �.f f S(/0 ❑Paid in Full ❑Outstanding Balance Due:
►^1Gl % L Y3 T u CT NT Sites
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisoi'`Liceose(CSL) p,3�� ;_/'I /7
MrtTJT6dr tom( ,,,,,. License Number Expiration Date
Name of CSL Holder
r I'w List CSL Type(see below)
3`'I .Q LG1GvI r.✓
No.and Street Ty-e Description,.
Sfyl C.W) O/q 7 L) Unrestricted(Buildings up to 35,000 cu.ft.)
R I Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
6)7 `I7_71j, SF Solid Fuel Burning Appliances
d ( q f✓(x.>';'� ,I I Insulation
Telephone Email address V D Demolition
5.2 Registered Home Improvement Contractor(HIC) 17-9.?/1
kW,t tt k'�✓ 13 r')dt['/ HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
34 BLu c'Nr Ct liL rciL& IMDGN wG�ncb U)t`r/J
No.an Street Ll7` 77� Email address
r 4 7u 9 L
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 r" 6td;� i
to act on my behalf,in all matters relative to work authorized by this building permit application.
M4 I bt4P,C, -ghl 6
Print Owner's Name(Electronic Signature) Date
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.
rN v1 1// � -4 at, 5AItc
Print Owners 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.ntass.sov;bca Information on the Construction Supervisor License can be found at www.mais.=og, v/dns
I When substantial work is planned,provide the information below:
Total floor area(sq.ft.) 'l72�<' (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.)--'It 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 n z7 Enclosed Open Ll�—
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Comm0 wepJth ojMassachusetts
DeparTment oJ'IRdustrialAcpdenls
I Congress sow^suite I##
Boston,Af402114-2017
www.ma=gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contrador&WAectdcians/Plmnbeas.
TO BE FILED WITH THE PERWHTM NG AUTHORITY.
AnoltcantLo�ietion PleasePsiat Ledbly
Name(Bosmesso, irasan�rom.,m>sij; WIr�QLcw Gy.h-Q-E32-ctr`��1
Address: �39 8e_jf yr aA-' Sa I et✓j
CityJState/Zip: 6 C((7(/ Phone M 617 177 77Y3
A1. ®empmatZthe apprpeat Di: Type o project(icilulRd):YewAffi wail �(M o+Pw-b=)• 7. O N Construction
2.Olamawk ptQpnebrorpaamaahip®dhave ao empbyam wing for me in 8: : R.emodplmB -
amyeapaeiry.[No wo�hvs'emop foaomee tegdaed.)
3.OIm aDomeownerdoiog dl work myaeN.lNo wmkoe tamp.insiveaa rapmed..lt _ 9: ODemalition
40lata ahmiw erad wi0 be hfriog coubauon to cmdact as wont m mypmpuly. lwgl - 100Bm7dtag'bdd un.
ensue that all conhaama eiawDava wmkas'wmpmvoam ionnanae mare sole 11.0 Electrical rgxm' or additions
p°FiQ101a�'!D'p "° 12:Opklmbmg tepaiis aradditifms
5.❑iamagenualcohi wadd Marva DDed are eub•eoaoaetas listed ad arc Midwd AftL
76rae.aub•contraeta9abavemployas aodbave av�'avmp.+TMm,••"•••:- .0 repays.
6.Owcareacorporedonaod its olfiaerahave esacised lbeiigkt of extao)ptiompc.MGl.c. 14.0OOaer .. -<
152,§1(4),and vxbaveoo emploiees.lNo wmYeis'Ecmpmsunnce retpmdj ' .
•Aay ayphctioi flies check bad sl moat also 6gma Poe aeedan hahw ehowiag tbefr vmkeis eompmmpm pQDrytpl'an - .
t Homeownrrs who eiabmit Pori affidavit iodiu�gtbey are dares aD molt ttaslbv!outside nnlet euLa anew affidavit mdieaCos tua6'.
$CQnoaatorathat check this Dosmust Mched so�oditamW sheaduwiog the mateftDe s&cmaatimr ad Ate w maw of ntdh OM"have
b.cQnyP.tea.hMe.mplyyae4ftymnstpvndethea w-kM'.mmRpwwY employees. Htbe aq
l am an employer steal igproviding workers'compawa*n insrumreelor nay ems• 8daw fs tltepoliey andJob sale -
inforimadoa y�
Insurance Company Name 7� T!k`7 T ? ( �1 c,rlc/ L IJ
policy#or Self-ins.I.ic.# ylt-i/0 j 1'�7,.)is Papirstion Daft-
Job Site Address. 3 H Ae l hGyo I..i r Cityastamp: 5ao�&7 al4 yl)
Attack a copy of the workers'compensation policy deciaration page(showlegtbe policy number and expiration date).
Failure to scaae coveage as regimed under AiGt c. 152 §2SA is a tairmael violation punishable by a fine up to$1,500.00
and/or one-year impristl t,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to SMDO a
day agaialst the yioleto7.A copy of this statement may be forwarded to 9�e Office oflnvestigations ofthe DIA far insiiiance
coverage verification.
I do hereby certify under thepains andpenabies ofperjury that the Information prmvded above rs true and correct
Sianataae
Phone#•
0jokW use only. Do not write in this area,to be completed by d0'or fawn of lcw
City or Town: PermidlJeense#.
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cltyfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or writtep"
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance witb the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the conbactmg authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number fisted below. Self-insured'companies should cater their
self-insurance license number on the appropriate lime.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pramit/license number which will be used as a reference number. In addition,an applicant
that=ad submit multiple pernut/hcense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit mast be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bun leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Deparuvent of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017.
Tel.#617-7274900 east. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CnYOFSALEg MASSAcHmm
BuzDmDEPArjmu4r
120WA9WVMS7RWrADM
lit.(978)745.9595.
BII�ERLEYDRISQ7LL PAX(978)740-9846
MAYOR 7)J3MSTTMW
DaEcrcitcFpuujcpxcnmlBuumiGccmmcm
Construction Debris Disposal Afdavit
(required for all demolition and,.renovation work)
in accordance with the sixth edition of the State Building code, 7B0 CMR, Section 111.5 Debris,
and the provisions of MGL c40,S 54; Building Permit it is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 311,S 1WA.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
v—�^�{teller
(name of facility)
(address of facility)
Signature of applicant
Date
F 1516`I
Professional Land Surveyors 8 Civil Engineers
ESSEX SURVEY SERVICE, 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1885 - 1972
PLOT PLAN OF LAND
LOCATED IN
MASS.
JN L %Y II;
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I hereby certify to G" -5/z!; `
�ul ,r; !/{✓ :>,': that the
buildings are located on the
ground as shown.
I CHRISTOP 65�
SCALE: 40 a R
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DATE: dut, 21 c�G?�'' 317�0)
�" Mello 'm'
REFERENCE: � SK I L PG � ) istoP herR.
104 LOWELL STREET
PEABODY, MASS. 01960
(978) 531-8121
FAX:(978) 531-5920
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