16 BUFFUM ST - BUILDING INSPECTION �Tp - �1_—� The Commonwealth of Massachusetts Board of Building Regulations and Standards G, I p q S CITY
OF C ITY
ALEM
Massachusetts State Building Code, 780 CMR, 7°' edition Revised January
Building Permit Application To Construct, Repair,Renovate Or Demo IVED 1, 2008
2 _ L./ One-or Two-F=ily Dwelling � ICNA SERVICES
This Section For Official Use Only
Building Permit Number: Date Applied: 2b
Signature: c __
Buil din g Commission l n'pector of Buildings Uate
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
_/_6-/3eGF�r/�t_S
1.1 a.Ts 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 OWNERSHIP`
2.1 Owner'of Record:
-P (��r—�cs? Icy 13 UFF_0m S�
Name( .' t) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW (check all that apply)
New Construction❑ 1 Existing Building ❑ 1 Owner-Occupied ❑ 1 Repairs(s) V1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ J Other ❑ Specify:
Brief Description of Proposed �4C7/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I_Building $ 1. Building Permit Fee:S indicate how fee is determined;
(q. D o A
2.Electrical $ ❑ Standard Cityfrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: _
5:Mechanical (Fire $ T — --
Su ression Total All Fees: $
Check No._Check Amount: Cash Amount:
6. Total Project Cost: $/0J vv ❑Paid in Full ❑Outstanding Balance Due:
M " t; -To o v--t✓1 u
- -C I 3 I
I SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) g3 G I S 2 -/3- l Sr
n A)Cl- License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) U
-5_--�—Qr-ch.arcf Sf_ a /errs mP
Address PRC
Description
Unrestricted(u to 35.000 Cu.Ft.)
S .ature Restricted l&2 FamilyDwelling
Mason y Only
7$- -7 V t/- /QQ/ Residential Roofin Covering
Telephone Residential Window and SidinResidential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
ITs9_b�(JB1 s h 14 8 y a 8
HIC Com any Name or HIC Registrant Name Registration Number
— r_r-b.a cam? Sct l `m_�r q a 7 - 15
Address
—.�✓� ci 78�7 qV.l 001 Expiration Date
are Telephone
SECTION 6- WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 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 .......... W No ...........0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
b `t�/ 0. p.-r p j as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to vork authorized by this building permit application.
A;Lci � i�j oZs ZD I
Si na ure of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I. ZA-)CL(S in 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.
,JA-6
Prmt Name
Signature ne or Authorized Agent Date
Si ed nder the ains and enalties of riu )
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.a 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1`10.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq, Ft.) 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 Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
o CITY OF sm—Emll 2ANSSACHUSETTS
1r 5V a-DLNG DEPAMtENT
fib tr 120 WASHLNGTON STREET, 3'n FLOOR
TEL. (978) 745-9595
R.x(978) 140-9846
UN(BERLEY DRISCOLL
IN AYOR THo.%vsST.P1ERRs
DIRECTOR OF PUBLIC PROPERTY/BUUDI:vG COSLRII5SIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Etectrfeians/Ptumbers
applicant Information Please Print Legibly
Name(Business Organizatiorufndividual):
Adtlress:��Q�pr-pl S�-
City/SratclZip:_ I_PA-r, MF) C2 IS2? Phone]: 7$- -7Y'/- /004
.Are you an employer?Check the appropriate box: Type of project(required).
I.FAN I am a cmployc' general
with�� 4, D I am a genal contractor and 1 6. ®New construction
auployees(full and/or part-time),* have hired the sub•coruracton
2.D I am a sole proprietor or partner- listed on the attached sheet.: 7. D Remodeling
ship and have no employees These sub-contractors have a. D Demolition
working for me in any capacity. workers'comp. insurance. 9. ®Building addition
[No workers comp. insurance 5. D We are a corporation and its
required.l officers have exercised their 10.0 Electrical repairs or additions
3.D I am a homeowner doing all work right of exemption per MGL 3 I.[] Plumbing repairs or udditions
myself.[No workers'comp. C. 152, §1(4),and we have no 12.0 Roof n pairs \/insurance required.]f employees.[No workers' 13.[SOther Ca;f t C Y � ti
comp. insurance required.] '
•Any applicarn tlw ducks box st mutt also fill out the sectiae below showing their worked'compenatiw polity inib matiom
't hwn¢uuners who subrttit this.sbldavit indicating they arc doing ail tvork and then hire outside contractors mtat submit a r+esv affidavit indicating suet,
-Contmcton that check This box mutt anachcd an addidural shin showing the name of the subeantnpots and their werkers'comp.polity tnforrration.
l urn an emplayer that is providing)porkers'cornpensadolf insurance jar my empluyeez, Below is the policy and Jab site
information.
Insurance Company Name:_ L L e rf y_lY)��-y a-
/
Policy p or Self-it s, Lie. tl: �s�?�/A�p/a Expiration Datc: � 5 - )14
Job Site Address: I Co. 6 Wr Jrn i Sc I? m CitylStatrlZip: M 19 O/9 7 d
Attach a copy of the worliers'compensation policy declaration page(showing the pokey number and expiration date).
Failure to secure coverage as required under Section 25A of�1GL c. 152 can lead to the imposition ofcriminal penalties,ofa
line up to S3,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and o line
of up to MOM a day against rite violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investiyutiutts of the DIA for insurance coverage verification.
/da hereby certify under the pains and penuhies of perjury/fiat the infarntutlon provided above is True and correct
Sit • ti
— - Date,
tTsone �j 7 7 '{e/ - / 00
Leerson.
c u,dy. /Jatobacopebycyurawn. Parmidf.lcensellmrity(circle one): —f Ilealth 2. (3uihlin; Deltnrtntent I City/Potvn Clerk 1. Electrical Ynspoctor 5. Ph.uubing lnspeetar-rson: - Phone tt: 1
Massachusetts -Department of Public Safety .
Board of Building Regulations and Standards
Con,truction Supen i,nr
License: CS-083615
JOHN WALSH
52 ORCHARD SL' •,i
SAL£M MA 019?0 Y�
Expiration
Commissioner 02/13/2015
y
- U/6e (pn7�t��zo'/arbarzt'C/6-o�(�/f��JJtic�r�5ead
rI
rce of ConsumerAffairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
gistrahon 148428iration 92 DBA
7/2015 Type:
THE CHIMNEY COMPANY, .
j JOHN WALSH
52 ORCHARD ST
SALEM.MA 01970
r Undersecretary
s..