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0006 BURNSIDE STREET - BPA-14-1060 * TPJ— Iq — LDS 7032 3 s - The Commonwealth of Massachusetts RECEIVED CITY OF Board of Building Regulations and Stan#OECTIONA,L SER ICESSALEM Massachusetts State Building Code, 780 CMR Revised1Vfar2011 Building Permit Application To Construct, Repair, Renod5140JURetrtTs 54 One-or Two-Family Dwelling This Section For Official Use Only [Building Permit Number: Date AppF d: Building Official(Print Name) Signature VDate SECTION 1:SITE INFORMATION 1.1 Pr perry Address: 1.2 Assessors Map& Parcel Numbers (� d v s!d _ A t/e. set l-'n 1.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.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❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: $It MW4-h dr .7Un e3 �o �/�. ern �slde /P;4e sa/erg 0/970 Name(Print) City,State,ZIP 0No�130rh 8 978- '`/0 to -5/9J_ .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) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Beef Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costs(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: U ' 5. Mechanical (Fire $ Suppression) Total All Fees:$ I Check No. Check Amount: Cash Amount 6. Total Project Cost: I^st: $ J. ❑ Paid in Full ❑Outstanding Balance Due: gVl�tl� � � IC� cz�4 c(Y/V�, c SECTION 5: CONSTRUCTION SERVICES 5.1 Construction SaperS,isol l§ceuse(CSL) ��r,. 7t:rr� 9 C t 7 'Q yl �SN' License Number Expiration Name of CSL Holder/5 t-1 .� (' i e"•'U+L )�� List CSL Type(see below) t7 l3a��le� A ✓ No.and Street Type Description O/9� U Unrestricted(Buildings u to 35,000 cu.ft.) CJaJQ (J,SZ /`�1Q , R Restricted I&2 FamilyDwelling Cityfr�ovb ,State,ZIP M Mason ry RC Roofing Covering WS Window and Siding 7 �1 SF Solid Fuel Burning Appliances 76 90� r 0 Insulation ' ele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1 1 1/ J 3 AYnerleaM 1)a0r- ` 0,nd0(1) HIC Registration Number Expiration Date HIC Corn any or HIC Registrant Name 1594llel( A✓e No.and Street ' Email address SLtOgus, n40 o/gOP 7B/-369 -7GP-Z Cit /Town, State,ZIP 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 9f 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 6 )1 P LC? to act on my behalf,in all matters relative to work authorized by this building permit application. / Peafher ;)one's G / 17 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.. Print 0 ner's or Authorized Agent ame(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.mass.gov/oca Information on the Construction Supervisor License can be found at www.tnass.gov/dps 2. When substantial work is planned,provide the information below: Total Floor 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" J CITY OF SAI.EIM, NL LNSSACHUSETTS BUILDING DEPARTMr-NT �R f:tl 120 WASHINGTON STREET, 3"°FLOOR 'taab TEL (978) 745-9595 Fox(978) 740-9846 KINMERLFY DRISCOLL Vf iYOR THoMAS ST.PTEM DIRECTOR OF PUBLIC PROPERTY/BUB.DLNG COMMISSIONER Workers' Compensation Insurance Affidavit: Duildcrs/Contractors/Electricians/Plumbers .Applicant Information �� ppqq���,t y!�/ Please Print Legibly V one(Businus.v(Jrganizatioro'Individual): r.(/trrs V/..�-mil 4, U/if(.� ! Address: l3 �A a.Q2cf �iuC City/State/Zip: ' 0110fr Phone #: Arc u an employer!Check the appropriate box: Type of project(required): 1..CJ t am a employer with �_ 4• ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or_part-ume).+ have hired the sub-contractors 2.❑ lama sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and have no employees These sub-contactors have S. ❑ Demolition working for me in any capacity. workers'comp. insurance. y. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation mid its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t employees. [No workers' cutup.insurance required.) I3.❑ Other 'Any upplicuni dial chucks box AI must also fill out the section below showing their workers'compensation policy ina,rmation. 'I Lvnnswtxn who suhmit this affidavit indicating they arc doing all work and then hire outside contncion most suhmit a new affidavit indicating such. ('emmaun that chuck this box must anachod an additional shad showing the name of the subeonlncton and their worken'camp.policy infomution. I ant an employer that is providing workers'compensation inssterunce for my employees. Below is the policy and Job site injonuution. n q Insurance Company Name:-4C !X/1W l.�'• Policy N or Sclf-ins. Lic, d: �L) C S 1 _�8�Q9_/y 3 D1" Expiration Date: // /1 11� Job Site Address:� �dti sd�.eY�1'l City/State/Zip:,44 d/9 0 (p _ Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500 00 and/or mu-year imprisnnmcnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S230.00 a day against the violator. Be advised that a copy of this statement may be furwarded to the Office of investigutions oldie DIA Far insurance coverage verification. /do hereby certify under ate pains atd penalties of perjury that the infonnutlan provided above is true and c'orrece tre; 1 � x. Offic'iul use only. Do not write in this area,to be campleted by city ur town official s Ciry or Ttiwn: .—_ Permitfi.icemse N Issuing Authority (circle one): 1. Board of Health 2. Building Department .1.Cilylrnwn Clerk A. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: [ CITY OF S'U:zN11 A-1S&kC1iUSE ITS ©CILOLNG DEP.IRTNeNT I_'0 W.ISHLNGTON� STREET 1'°. FLOOR tiY T EL (978) 7►5-9595 F.Lx(978) 740-9844 K1JBEltLcY DRISCOIl. ,%VLAYO"l THOSU3 ST.Pjz= DIRECTOR OF PUBLIC PROPE1%TY/8CILDLNG CO\WISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 OAR section l 11.5 Debris, wid the provisions of NIGL e 40, S 54; Building Permit #this work shall be is issued with the condition that the debris resulting from l 11, S ISOA. disposed of in a properly licensed waste disposal facility as defined by t41GL c The debris will be transported by: y (name ut'hauter) The debris will be disposed of in (axne or -- (aJJress ot'taeilit/) signarurc urpermit applicant thle 1' 1 1 •: 1 1 1 I ' 1 I � 1 1 ' I 111 11 1 r 1 Ir Ir 111 1 1 1 - 1 ' ' 1 1 1 • w �-*�E.... v•`. Ste*'" F n (�5���� I&�� 4'4✓`fi4`�.t ,c f.�' .�`I.lea � -� i t x��,�AA,, "I! �hrL"�{ ax4c'm s'y_ tfiy .yr n ar ��" •tY7..s ,r1F �'Aq r^T {�x"��+f,}'L��A �ro tr4 AEG ak� � t `r:'�@ '�''• �' � �. s 11 Y.I r41=�. e+y nlr,�,a a��a� { I va'.,r ,✓�+' � '� itt { ,�'F�.+}c n � a " � � .� fu��,.''�za k'} �`"�� f// ' 'P�r14�."" S`'Y�"' r '# aSf✓r„it Y,p t yea mar: "YVS��"ty 4 ''ac !: s s^.'y,.3F•.�' c" £`b r w S X I{.' ��A•ss � �.'. �'���- � F �� rxr ..3&...;dL..�,�.r�'�S.i•s• .+t'�aau.-? ':tus999«<�'?;`^�.,''�'I �'.lur4 ���''�. 1 1 r ®® 1 1 ®® grl MOM c3. ��ai,�{d4 j $Yf:L�yl aY +f,�4i1�� li �S3•zF -�- Ais�.st+w k�F1'*..n.a�.+kcd�rt�w k�� ��: �'.'s�a�x: s�i •x' 1i� n Yea MvG -k�a�.* 6 ,g VHF• �`' cam' p-+. .^y ,,rw,yg '�q >G 1 1 1 1 1 mom I © 1 -..� »�.x:{aaac4b� �+s�`;m•a�•. CEt �,h .+L .. `,.#i'� �:..�+�n"� �.lt ^�nz•`.s''. ` i'��,� � Pa:�� - 'ClothesExhaust dryer vent including � .[' I I I I � 1 1 ■■ Duct kit/bathVent � .t' I I •1. i t � 1 WAP Work Order: Job Number: 140097 Domestic water pipe wrap 6 $2.63 $15.78 6 $15.78 Attic sealing with two-part foam 3 $75.00 $225.00 3 $225.00 Basement sealing with two-part 3 $75.00 $225.00 3 $225.00 foam Blower door set-up with pre&post 1 $45.00 $45.00 1 $45.00 tests Connect downspouts 1.5 $60.00 $90.00 1.5 $90.00 Seal ducts with mastic or butyl 3 $65.00 $195.00 3 $195.00 backed tape Secure attic ceiling/falling down/ 1 $60.00 $60.00 1 $60.00 fasen Weatherstrip(Q-Ion or equal)attic . 1 $31.50 $31.50 1 $31.50 hatch Ewe EN b i Building Permit 1 $100.00 $100.00 1 $100.00 t^ , Wood clapboard/shakes/shings or 1317 $1.79 $2,357.43 1317 $2,357.43 vinyl(dense pack) Total $4,1 $4,977.05 Contractor Instructions: Before Starting the Job: During the Job: 1. Please notify us 24 hours before starting or scheduling a job. 1.This residence was built before 1978. Lead safe practices are 2. Obtain required building permit. required. 2.Total for Heath&Safety and Repairs cannot exceed$2500.00. 3.Davis Bacon time sheets required for ARRA work on US Department of Labor Certified Payroll Report Form WH-347. Date:3/13/2014 Page 2 y Massachusetts -Department of Public Safety Board of Building Regulations and Standards-^—t Construction Supervisor Specialty f License: CSSL 100824 W]LLAMJDELOGLS IS RAELEY STREET SAUGUSUGUS MA 01406 -"Uq Expiration Commissioner 05/05/2016 Office of Consumer Affairs&Business Regulaonet/. ,A OME IMPROVEMENT CONTRACTOR • egistration: 111123 r xpiration: 11125/2019. Type: AMERTCAN DOOR WINDOW&INSULATION WILLIAM DeLANGIS- 15 BAILEY AVE _ SAUGUS,MA 01906 - --�- -- _ Undersecretary