The URL can be used to link to this page

10 BOARDMAN ST - BUILDING INSPECTION The Commonwealth of Massachusetts C OF �•, Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 730 CMR Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dtvelling This Section For Official Use Only. Building Permit N mberr D' pph Building Official(Print Name Signatu 777 - Date - SECTION L SITE INF09MATION 1.1 Pro jerl Adess: / 1.2 Assessors Ma & Parcel Numbers p L la 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 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERS 2.1 Oywnerl of Rea _7 Name'(Pr nt )�K� / City,State,ZIP ( meg( �' No.and Street - Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ I Addition Cl Demolition ❑ Accessory Bldg. 13 Number of Units . Brief ascription of Proposed Work':To L VV , 1 �/ /Lru �. SECTION 4: ESTIMATED CONSTRUCTION COSTS_ Estimated Costs: Item Official Use Only-. Labor and Nlaterials 1. Building I. Building PermitFeer S Indicate how fee is determined: / C1 Standard,City/Town Application Fee 2. Electrical C20 i ❑'fatal Project Cost'(Item 6)x multiplier x 3. Plumbing i 1 0 0 v l ?- Other Fees: 3 t. Mechanical (IIVAQ 5 List: i. Mech:utical (Fire $ Sii> n'essioit�_ Ibtal :111 Fees: $ I J�D Check No. Check Amount-. --cash \mount I'MA Project Gist $ 0 Paid in Pull Cl Outstandm" Il,11,111c.. Dir •: SECTION 5: CoNsrRUCTIOIN SERVICES 5.1 Construction Supervisor License(CSL) ,f1 t( 6 7, License Number _ Ir;ttion D, e I Name of CSL I lolder List CSL Type(see below) 3 6 0 0 r%H. f (/ f Type Description No. and Irtet SU Unrestricted Duildings up to 31,000 cu. R. CO R Restricted 1&2 Family Dwelling Cityirown, State, ZIP ivy Masonry RC Roofing Covering %VS Window and Siding _ /� SF Solid Fuel horning Appliances ✓C � Ail, y) 3® �Jq' / I Insulation I'e a hone o"X�L�Lc Email nddrtss D Demolition 5.2 Regi ered Hor p /ate Im rrooyPment Contractor(IIIc) f ,q //' C' ` HIC Rzgistration Number xpir:tion Date 111C Col y Nal ' [IC Re strant Name h ` No. and tre tEmail address IT— Ci /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 .......... (7 No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTO PLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize �^ �� aui `�� to act on my behalf, in/af all matters relative to work authorized by thi uilding permit applicZ;�6 f/'nY l ,oilICS/4e � ? �f Print Owner's Name(E ectr is Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my nes elow, [ hereb nder the pains and penalties of perjury that all of the information contained in tl ',❑pplic tion is uc and acc ate to the best of my knowledge and understanding, _ �I Print r Autlwrited:\;ant's Name(Electrunic Signature) utz 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 Honte Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty bold under M.G.L. c. 142A. Other important information on the HIC Program can be found at www.mas3 Loy/ova Information on the Construction Supervisor License can be found at tsww.mass...ov dLn 2 When substantial work is planned,provide the information below: Total tloor:reu(sq. (t.) _(including garage, tinished hasentent/attics, decks or porch) tyros; living area(.Sq. ft.) _ _ Habitable room Count -- Nmnbtr of tircpluccs_---_----— Number of bedrooms _ — _--_-- Number o f bathrooms Number of ImI L baths --- I apo of lleahtlg sy Ctelll __— Number of decks/ poli f lit! ,tfro,limgl ;y,lun — fuclosed - 4 1 I- It II I'I qu t�yuu Pant 1 � in ly he ,nb;ttliu J 1,I I' ,Lil Ihu�cet ('n t . A7 s r u CITY OF &UXN15. INL�SS'ACHUSET B ,• BtiILDLNGDEP�RTJIE.iT 130 WASHINGTON STREET,31°FLOOD TEL (978)735-9595. F.4a(978)740-9846 KI\IBEX[ F.Y DRISCOLL THOMAS ST.PMRRE MAYOR . DIRECrOR OF PUBLIC PROPERTY/BUMDLNG CONMUSSIONER Workers' Compensation insurance Affidavit:Builders/Contractors/Eiectricians/Plumhers A licant infortnatinn Please Print Le •bl Name(ousinessiorganizatiorvindividuat): i Address: •� �y �p 7 City/State/Zlpi f .{"4 Phone M: Are you employer?Check4jile appropriate box: , Type of project(required): 1.Vam aemployer with 4. El am a general contractor and 1 6 ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.(] 1 mei a sotc'propricror or partner-1 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 (Now rkcra'comp.insurance, 5. ❑ We area corporation and its 10.0 Electrical repairs or additions ired.J. officers have exercised their reyu }.C1 1 qu a homeowner doing all work right of exemption per MGL I I,❑Plumbingirs repaor additions myself.[No workers'comp. c. 152,§I(4),and we have no (2.❑ Roof repairs 'insurance required.)t employees.[No workers' l3.❑Other comp.insurance required.] •Any appltatr4 that check&box pi must also rill out the section below showing their worker'cempeas olms policy information,. + t I t muowmer who submit this affidavit indicating they are doing all'wrork and then hire olnide contractor must submit a raw affidavit indicating such. 'Can mann[that check.this box meet attached an additional shed showing the.name of the subaeomnctots and ihek worker'comp.policy inJorteaaen. lam an employer that lr providiaw)porker'compensation insurance for my employee. Below Is rite pollry and fob site injormmian." 1 1 Insurance Company dame: s Policy 4 or Self-ins.Lic.M. Expiration Date: - Job Site Address: City/State/Zipf Attach a copy or the workers'compensation policy declaration page.(showing the policy number and expiradon date). Failure to secure coverage as required under.Section 25A of MOL c: 152 can leadto the imposition of criminal penalties of a 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"a fine of up to$250.00 a day against the violator. Ile advised that a.copy of this statement may be forwarded to the Office of Investigations of the DIA ror insurance coverage verification. I do hereby zee ' car the pu -and ,rallies ofper ry that thisfitforniadan Daptrco•vided'abtrid correct 11 Vi ra t ; Skma Phone 4: Official use only. Do not write in this areas to be completed by city or*town of HOL City or•town: Permit/I.Icense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cilylfown Clerk 4. Electrical Inspector S. Plumbing Inspector b.Other , Contact Person:. Phone#: ;•y Cin OFS:V-ENf1 tbW&wFiusETTs •i\• f: ,`1 � Q�tLD4YCDEP.1RTSlE.tiT 1_'0WASHNGTO, STUzrp1 °F�OOR \ � ; TEL (978) 745-9595 KI1(JERF EY DRISCOLL FVC(978) 740-9344 UYOR - tO1N9ST.PIEAAB DI:tECTOR OF FLOCK PR0PERTY/8':=LYG CONWISSIO.N EA Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accardanco with the sixth edition of the State Building Cada, 730 C,-vIR section 111.5 Debris, uid the provisions of MOL c 40, S id; ©wilding permit N is issued with the condition that the debris resulting from this wurk shall be dispuscd of in a properly licensed waste disposal facility as defined by NIGL a l l I, S ISdA.= The debriswillbe mwsportcd by: (nantC uChaulur) Tho debris will be disposed of in : AN is ut Yaci —_7T�r1jh ;(- +i�tuanua ntpermit applicant