8-10 CEDAR - BPA-13-37 I'he C'omnwnlscahh of bl;usa�husclts —
1V Hoard of luiding Regulations alld SI;mdards CI 11 OF
sl SIasSNAlt'setts State Building Cudc. 7SO C'hIR SALEM
'ti%,.' Rari.�:J Ilur:rlll
Iuildiog Permit application To C'onslnlCL Repair. Rellnvate Or Demolish a
(h)e-or rt1'rr•rL a mill' Du ellnnq
This Section Furl icial USC Onl
Building Permit Number Applied:ate
V4 2
Iluilding Official(Print Niune) Sigrtaturc r pale
SECTION 1:SITE INFORMATION
1.1 P,rroperty AJdreu:
/[ly ( 1.2 Assessors Map S Parcel Numbers
t�- :
I.la Is this an acce ted street? es no Mop Number Parcel Number
I.! Zoning Information: 1.4 Property Dlmenslons:
Luring District Proposed Ilse Lot Area(sq II) Front ago III)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. JU.§!4) 1.7 Flood Zone Informatlon tl: l. Sewage Disposal System:
Public❑ Prig ate O Zone: _ Outside Flood Zone1 Municipal O On site disposal s +:cm O
Check if cs0 P Du )
SECTION2: PROPERTY OWNERSHIP,
2.1 pwner'of Reys{d:
(9t.4f1s/ h��rce �In,. ✓y�lYlE
N;uI:L!(1'nn1)t (uy,llatc,L.IP r
Nu.:mJ Street relephuna Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 E.r(sting Building D Owner-Occupied ❑ Repairs(s) O Al eratlon(s) ❑ 1 Addition O
Dentulition O I Accessory Bldg. O 1 Number of Units_ Other pecily:� h �_� F2e
Brief Description of Proposed Work-: e
Roo
SECTION a: ESTI,A ATED CONSTRUCTION COSTS
hells Estimated Costs:
ILabur and\latrriab) OlTiclul Use Only
I. Building S 6Ue0-Uir I. Building permit Fee: S Indicate how Ire is determined:
'. I:'lectrical S ❑Standard Citffu%:n Application Fee
O Tutal Project Cost'l item 6)s multiplier
I I'lumh10g S 7. Other Fees: S
J. \Ivih.ulii.d ill\ NC) S List:,_ .--_-
5 \lerhuuic.il IFire _'--'-- -- --- f
� 1 ,uev ion I S rotai .\Il Fees: S -
n / Chad \u. -_ ___(hccA.\nnnntl: _ -. .._. .C.11h \momw
llllal Prnjecl Cost: S l/
7, b�C9 U0 l7 P.lid in Full 0011151:lnding ll.il.mee Due:
SH IIONS: ('ONSI'Rlf'fll)NSVMWFS
.i.l ('unslrucI ion Su lie nisurLicense(CSL) �p7 � .. a-i(7 rY
I iu'n,c \'unihcr P%piraoi,n 1).oe
N,inw"drVl II„IJer ---- Iisl01. r,peLee1,611%I.__._1`�-_ .._
QOLLcti.�
No. ,tin).trect (i (htrestrieicJ I IludJi]1-s 11 to)S.UUO.u. 111
It Re.IrieteJ 1C31'.11111 Ot+ellin
l'il)i(re a.SlalC, .II/ %) Simon
tic H,%,lin C'o%crin
N'S N'indim old Sidin
SF .Solid Fucl llurnins Appliunccii
I Institution
`�/ SYi�/I �1 _ D Demolition
I QIV bona (mail uJJrcs
t,2 Reglstered flume Improvement Cuotractor(HIC) �47=_
IIICifegislralwnNumkr RvinntuunDule
I IIC C'onlputi) Nam:or I IIC Itegistrult Nuntg
Ernuil address
No.��utsd Street
Lt N/J .
Ci own, Stnte ZIP Tde hone
SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L.c. 132. 1 3SC(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 Allldavit Attached? Yes ..........vl� No...........O
SECTION 7a1 O\it'll —El AUTHORIZATION TO BE C0111P LET ED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Date
print Utater's Nwne(Electronic Signutum-
SECTION 7b: , """ I 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.
\ /�.= DuW
print Dencr'i ar \uthorireJ.\gent'+Nome Ilileclnmie Signauuel
NOTES:
I. An p%%ner s%ho obtains a building permit Io do his.her own ssork,ur an owner svha hires an unregistered contactor
I not registered in the Hume Improvement C'untractur I HIC) Program),svill w have access to the arbitration
program or
guaranty fund under\I.G.L.c. 1 4'..>. Other imponant infurntation on the HIC Program can be Ibund at
tt,t,t n�,i.• +, • . I Infornwtiun an the Construction Supervisor License can be found at +%w, ���•,•' "t '�I^
U hen substantial ssork is plmuned, pro%ide the infurmaiiun below:
fatal Maur area 1 iy. Il.) . ____.._I including garage, finished basement attics. Decks or porclu
ftobllable rounn cotint
Gross Iis ing area isy. ILI ._.. ._. _... . \Uniher of hedroomi
\till ibcr of,Ilrepinccs .. _. ._ _._
\muherot'hathrooms _ \unlberot,d" po l
\Umbel ��1'decki porches i
I\pe of healin I'nclo.cJ
g i)Diem I)pen
I\pc d.'o,+ling
I i'oial ilroled 1,giorc Fooi,Ige" MAN 1'c uh,ll tl1chl (Pr I'oml lroye t ('till"
C ITY O F S.1LE M9 N Ws ACH Us ETTS
' ) (3ULDING DEPAIUMENT
1 0 %V.1SH V ' Ica L (.TON STREET, i FLUUR
TEL (978) 745-9595
F.Vr(97,9) 7 tQ.9844
Vj`•taE,•iLEY MUSCOLL
NLAYO:Z - I�IOtiLi3ST.P1ERR1;
DIRECTCROF PL'9LIC PROPERTY/aUrLo NG C01L.ILSSIONER
Workers' Cumpensatlan rnsurance,%lYidavit: guilders/ContractorwElectrlclans/Plum bero
%yolle;int Inrormatlnn Please Print Lt,zlhly
.V lttnl:(nalllld\Y Ul�.7nl rlllafL ladl Vllhlal). /JIII,ay.�lrzn HA t -h2 % •cyra.,r
Address: s IS %4=62 21yr S
CilpStatc/Zip: L uaj IhA, ors y PhuneN:_•7E/ S59 /a i
Are you an employer'!Check the appropriate boa(
I.(fin a employer with _1 1/ 4• ❑ I am a gunervl contractor and I type of project(required):
cnlPlnycw(Rill and/or part-time).• have hind the sub-contractors 5. ❑Now construction
2.❑ fain a role proprietor or partner- livod on the anached.rhdaL t 7, ❑Remodeling
,hip and have no employees These subeontractors have R. 0 Demolition
working for me in any capacity. workers'camp,insurance. ,
(No workers',comp, insurance 3. ❑ We are a corporation and its ). ❑ Ouilding addition
rcquircd•) officers have dxereised thalr 10•❑Electrical repairs or additions
).❑ I ran a homeowner doing all work right of exemption per MM I I.❑ Plu repairs or additions
myself. (\'o workers'camp, C. 132, 11(4),and we have no 12. oof n:paira insurancd required.) f umpluyecs. (No workers'
cump.insurance reyuircd.J IJ•QOlhcr
•.any appll,:uH our eh,�Ya boa I I mwUlyy fill raw Iha wetiw hutaw ahawine IAaiI wrYao'eompanudun pulley inalrmmlon.
'I h.nvuwrtna who ruhmin Ihis afldxvil indicalna Ihry,n dainy all,wra and Ibcn hin uunide contmclpe mwl nlhmn a new alEdavil indfaine ruck
C,:mnrlun Ihnt chalk this 6ux mwt muhwl un IJdulured.heat.huwine Ilw nwne of the rat "Almlyre And'hall wmaere'rump,pulley Infwnraeos.
fain un rrnplayn that la pruvldlnX workus'rumptnrm/un ln.rwance�aa'my emp/uyrrx Below/s db pol/ry anti tub sUe
inJurrnullarL
In,ur:ulce(:ompiny Name: e- -rI
I'nlicy 4 or Self ins,Liu. ry: S�7 50�7 5
- Expiration Date: 4/-/ -/3
/ub Slte Addrass:_rg=�c� CEdaR A✓p .�
Cityistaterzip;�l•PM.m�
'ouch a copy of the worker'comparoatios pulley declarallan page(showing the policy number and expiration date).
E'Iiluru w�ccuru cuvemgd as rrquireJ under.Secllon 2JA ;fMGL e. 152 can Idad to the imposition areritnina)penalties ofa
tine up to il,SCOAU und/ur one-year impri.mmrM is well as civil penalties in this form of STOP WORK ORDER and u line
- (up fo 5-150.(Ia a Jay r,ainst the violamr. Ile advi.+dd that u copy of Ihia.ulelnent may bu furwerdad to the 01,1%j of
Ll%c,IIq,uons&d tllu 01A I:Ir i'lluNnCc cowr.1gc V�rltle.ltlun.
/Flu hrrrby coffi/y rlrrdu rAt palar urlJ ptnelrler,r/p,vjury r/rul drt it furnruNuu pruviJaJ uGuvr it trot and comet
rr1.i, 0dr
II//iciv!r,Ie ran ly, 17...... nvirt in du:r rrny ru.Sr cuta I'le Sy c,iy, ru lrn•,jjlriu!
C iry or I'uwn:
(.ruin;.dill rily
I. ;iu.Ird of Ilrallts I. Middlu Ucp.lrhncnt I. Cityf l'nnn Clerk I. fittctric.Il fray„th l'I
i,hooe A:
t'n Il.nl i'<rvm:
CITY OF S,U-&N(, NEUSACHUSETTS
dt;MDOIG DEP.IRTIEVT
I'O W-UHNGTON STXW, )i*FICCIt
rM k973) 741-9595
KI1�FJtlSY D4LSCOLL F.tx(978) 1449&id
MAYOR M0.%W ST.Pmae!
Df"CTOlt OF PLauc PROPERTY/31LQ.D0443 cowlISIIONEll
Construction Debris Disposal Atfidavit
(required for all dentolidon and renovation work)
In accordance with the sixth edition of the State Building Code, 790 CMR section 111.5
Debris, and the provisions of MGL o 40, $ 34;
Building Permit a is issued with the condition that the debris resulting front
(his work shall be dispascd of in a properly licemed waste disposal facility as defined by NIGL c
111, $ IJOA.
The debris will be transported by:
(name urhaular)
The debris will be disposed of in
—j
(name of fauiliry)
(rddras or rud,ry)
,yn�mra of;,erm,t rpplwrnr
�-Itao,2