2 BRENTWOOD AVE BPA 18-254 1
Fhe Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Cade, 780 CMR SALEM
Reri.erd.Ilur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Too-Family Di elthkif
This Section For Off 'al Use Only
Building Permit Number: Da Applied:
`I/Z9a�G
Building 011icial(Print Name) Signature Date
SECTION l:SITE INFORMATION
L I Proper ddress: 1.2 Assessors Map& Parcel tubers
I.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 It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ow ert of Record,
/�
Name( r tit City.St"ate,
)`ih rG✓d e 925V%23 dd
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
BriDescription of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Mlaterials)
I. Building S aa, I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical ❑Standard CityfTown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
i. plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List: �-
5. .Mechanical (Fire
Suppression) Total All Fees: S
/' Check No. _('heck Amount:
G. Total Project Cost: S S !/v� Cl Paid in Full ❑Outstanding Balance Due:
PI)o'c .
U N
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructiml Supervisor License(C'SL)
_
License Number q vut' t Dale
Nmne of C'SI. I folder
e& Lis CSL fype(see helow)
No. Id Street -- "Type Description
ll Unrestricted(Buildings up to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
C'ityr ro,m,Stine.ZIP M hlasun
ry
Rooting Covering
WV Window and Siding
r SF Solid Fuel Burning Appliances
!7 I Insulation
Telephone ('.mail address D Demol/ilian u
5. Red%i)sttered oo`melmpro%rement Contractor(HIC) / UG17
4lSc t u -"�` I IIC'Registration Number lispir wn Dote
I�C'ompa t) ame or I IIC gistrant Name
�� !L
No. d Su• t Email address
104
Ci 5/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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
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) 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.
D4y10 /V10�/2� l _ ter /z
Print 0„ner's or Authorized Agent's Name(Electronic Signature) Dale
NOTES:
I. An Owner who obtains a building permit to do hisrher 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. 1 12A.Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at,%kko ici <.gm.'dps
2. When substantial work is planned, provide the information below:
Total fluor area(sq. R.) t including garage, finished basementattics,decks or porch)
Gross living area(sq, fl.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbmhs
Number of decks, potrthes---
1)pcofeuolingsystan___ unclosed Open
1. •`Total project Square Footage-may be substituted for"Total project Cost"
CITY OF SM..E.Nl, NLASSACHUSETTS
BLLLDLNG DEPARTMENT
110 WASHLNGTON STREET, 3iO ROOit
TEL (978) 7.15-9595
NX(978) 740-9846
KiJtBERLEY DRL4COLL
MAYOR Tliosw ST.Pm us
DIRECTOR OF PLOLIC PROPERTY/BCQDLNG COMMISSIONER
Construction Debris Disposal Aft3davit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 t 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit At is issued wit
h 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
l 11. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
�--�-�
(name of�faicdlty)
( 1.1dress of facility)
signature ofpermi applicant
�aIC
IM1n ulf d•.
yv
CITY OF SALEM
PUBLIC PROPRERTY
LM
Ql�
DEPARTMENT
M:1 1':,MI,{.II I
\I N.M
1 C\VA,ftlAtilU.\)ISYlT • $Al1•.N,hi.r Un6iit V 1 nJI'17,^,
tiVbrkers' CbrnPM211on Insuruncr :U(1dlivih Uuilders/Con tractors/Elee trlclans/Plumbers
� I tllcant In onnglion
PI �� lint Le 'AI
N'"C 11)uarw,all)rasnvafiow Ind,v jual):
I honr il:_� 7�
%re {nu an vloplaye►:'Check the approllriate boy.
•Im a Cmpluyur wish e:;,— _ 4. Q I :un a dunuml coWrxtor and I I yM u(pro)uct(required):
L
yvus(full anJ/ur part•linte).• Nava hired the.'uh•cuntracturs h' ❑New construction
a sold prnpricmr or partner• listed on theanachcdsheet t y, ❑ RelnoJelins
nd have no umpluycus These iub•contrsctors haveny Air Ind in any capucity. workers'comp, insurance. s' QDamolirionorkurs'cutup. insurance J. Q We are a corporation and its q' ❑OuiWind aJJitiun
3. d.) officers Itave exeteievd their 10.Q Electrical repairs or additions
hameu,wtcr Joint'all work riyhe orcxdniption per&ML11.❑ Plumbinr repairs or aJJitinru
.Inb anrken'comp. c. i J7,¢I(4),and wt hnvd noce required.) r employees.h'o workers' 12.Q Ruul'repuira
cfnnp, insurancu reyuind.J I J.Q Other
•n nr,,,phcua drW enacb aen At marl:dw fill uW the.efuun 6aluw dweruq rAWr,rwYtali dun, nyaiun
'I lu,nw,rtren wha urhmil Ihif effhl�Wl i M ie u naluline ilyr Jle Juine uWfid,rumnr r ,rurrr,wiun.
•C.n¢wurn ihp{MyY this bast mute mand Jn all,fury and ihm him addiriunmom� ei.heel dluwine the"rare arthe lubl om t°q mWr.rrlenfl,1 c ",imilt inai{yin r
hxH.11a Jn#Ihen 4YAel11,e' a NY•
/urn all employer thuf If provi✓kit wurkerr'rurnpenfntlaa htfunince for my rfnp/oyeer Br/mv/s thrioulity und/o1 s
ife
iu/urnrutLrn.
Insuranuc C'unlpaay Valne:LZAll 1 i
Policy 4 ur SCIf•ins. Cic.n; — - _—•-
—�-- Espiratlon Date:
Jub Site Addruse:
C1ty'slateizip;.macho copy or the workers'wmpema:r.j piQn I Jceldrallun page(showing the policy number and expiration dues).
PJduro w,adore cu,eraye as required wider Seaiun_'JA ui'MU c. 152 eau lead to Ih#imposilign oreriminsl penalties of
ins rap ol.SI 500,r)n Jnd/orwif:I imprixuoincrit. Js ,vcll Js civil penalties in Ilia funn Of STOP WORK ORDER and a ring
ettilt to i?SO.gO a Jay idainat Ili#viol.onr. III!advl.+ed lhut a uupy nrlhis.,lalerrlent may be IurwarJcd to the Unicu,a1*
1'n'rsn,aurms ut';N¢ I11,\ IOf bIH1I:11'ee etriefJje,e1111eJ11Un,
/du hereby{rrriY un✓er the P411,11 un✓prnn//!ef u�pa/nry rhut fh#lnlunnuNon prvv/Jr�ubuve!t III nnJ momv
I'Ir J U / lr
Ii1)�l$'ier lee UIIIy. tlY,InI mire in rhlf uree, ru be rulnplerr✓by Lily Of forvn u/✓leiuL
r r itYVr Inwrf'. _
I, ILrJ n(Ihvlrh 2. Ihu6linj Ilcp.lrhucnl I Cil 'r ' lcneI„uing Authority (circo one); Pnnir/Le e
IrkJ6. Ofer CIccfr icrl furIf{,fur 4, Plumbing In,pcclor
I'hune -Y!
i
Information and Instructions
v person to o service Jt mother under Illy cuntr
• act of hire,
\Ia,.i.li haienY tlJnC(aI Law?chJptef 1�2 regWreY aII alIlplaya0 t0 proYldO wJ(kera NinpCO%Jhpn tnf Ihel(C1tlpIJyCCY.
I'ursuatu to tltts statute, in empltn." iY JetineJ is" ..e cry {><
: press or implied, urul of wnue"• of an two or Inure
urtneminp.,IS$ociamoo.corporation ter other legal deentity, if he
\n emplupvr Is detincd as"an mn, enterpl. p �mt loyees. However the
•.I the I;,regumg engagcJ m +lomt entarynse,and incluJing the legal represmuativas of a deceased employer.
aemver or uuatea Ill'.m individual,psrmenhtp,;cssaelauoi or other legal oozy,employing ' P
c eons o do maintenance,c""ruction of repair
be Beamed tocbe ineetnpluyer."
on
J cely r a treble 0 house having not snore than three apart"emu and who resides therctn,or the occupant of the
,Iwethng huu;a of unathet who employ. pe
or on he grounds Jr building uppurtenunt hereto shall got because of wch employ
�IGL M Issuance or
chupter 132, 425C(6)also states that"Ivory state or local Ilconslog ageeey shag withhold 1
taftwoullit for any
ce Of Ilaaea wits the Insurance coverage required.'
renewaI of a license or permit to operate a huslnas!aete construct buildings la the
its momlitic l subdivisi ins shall
•tpplicans Milo has not produ 1415Cep,,hr ear Neither he ommonwealth nor any D
ldditionally, %IGL chupter I S_, i- l
enter into any ontroet far the perfomwnce Ill'public work until scecpctble cviJanca of conipliartce with the insurance
requirements of his chupter have been presented to the contracting authority."
Applicants the boxes that apply to your situation and if
address and phone nwnber(s) s LLP with their certifications)Of no employees other than the
Please rill out the workers' compatsrtion alyldavit completely,by checking
necessity,supply sub-comractor(s)nume(s),
workers' eontpattsation inuurance. if an LLC or LLP does have
insw•unea, Limited Liability Companies(LLC)of Limited Liability Partnerships
inembers or pullers, are not required to carry be submitted to the Deportment of industrial
employees,a policy is required Be advised that This atP be s may %ISO attment of
accidents for confirmation of insurance coverage. Use be sure t license
and dui The ufsted,n. The affidavit shoal
nnit at lion»is being requested,not the Dap
to obtain a workers'
he roomed to the city or town that the upplic ;surd regarding the law of if you are required anies should enter their
Industrial Accidenu. Should you have any q
compensation policy,please call the Department at the number listed below. Self-insure comp
self-insurance license number on the a ro note lino.
city or Towe Officials
you to lill out in the event the Office of Investigations has to contact you regarding the applicant
please he sure that the affidavit is cumpicte ;Ind printed legibly. The Department his provided a space h the rum
of the affidavit for y
given Year, need only submit one utiidnvit indicating current
I'I:ase be tiro to till in the pertniHlicmisa nwnber which will be used as a reference number. In addition,an applicant
titat must submit multiple pennit'Ikaitse applications in any g Y locations o rovidcJ w the
policy ittformati'ij d1e u171duvii hu has been offlc ally sumd tinder"Job Site apcJ of marrkedthe tby;ll#ct y of town tnayep o .(city
tuwnl."A COPY mmits of licenses. A new 4ilidavit must be tilled out each
applicant as proof that a valid uifiduvit is on rile for iLtun p to any business Or
eer.t login rr1101n r Owner
r burn n islea o tams`ld P�Y 31 isicrinso or NOTtrequited ot not f complete'his afftdav emntereial venture
permi
I he 0slice Jt Invavtigatiuns would like to hank you in advance for your cooperation and shuulJ you ha%a•LAY questions,
please do not hesitao to give us a call.
f he Ucparuncnt's addrers, telcphune and rax"umber
The Commonwealth of)otatsachusetts
Department of Industrial Accidents
ofte of Invesd2atlons
600 Wuhinaton Street
Boston, MA 02111
"fat. p 611-717.4900 ext 406 or 1.817-MASSAFF
Fax M 617.727.7749
www.ma%&ovldia
Page# of�pages
CoDG Cmk,:�rfRuc-te-ai µ
r3 O0. 5 7—
S
q 7c? 33 r=;2(5,
Proposal Submitted To: ( Job Name Job If
�i OEOZeCIq
Address J -@..i. f... t '� Job Location
C to 1/t� Date Date of Plans
r ✓�
Phone#97 Q _ �q // / Fax# .- Architect
We hereby submit specifications and estimates for:-...-/,�P QX 1 . __- ��u � _.- � _!S Z �t2 6L 2L�24�e
__ate
I
— --
r cXN42 l St J
We propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of:
$ U d 1 Dollars
with payments to be made as follows: 2, o(-3 Ar"A4 yl
Any alteration or deviation from above specifications involving extra costs will be Respectfully �� `
executed only upon written order, and will become an extra charge over and \ I
above the estimate.All agreements contingent upon strikes,accidents,or delays submitted nr5''s—
beyond our control. Nate—this proposal may be withdrawn by us if not accepted within days.
w �cce�rance-of �ropo�al a
The above prices,specifications and conditions are satisfactory and are Signature t
hereby accepted.You are authorized to do the work as specified. t
Payments will be made as outlined above.
Date of Acceptance Signature
&r NC3819 MADE IN USA ,