17 CLIFTON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
s Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code 780 CMR SALEM
Mas g
Revised Mar 2011
\ Building Permit Application To Construct, Repair, Renovate Or Demolish a
Dl One or Two Family Dwelling
This Section For Official Use Only 7 x
Building Permit Number ' Date plied:'
BuitdmgOfficial(Print Narae) "° _` 'Signature „ „°; Date -
SECTION 1: SITE INFO ON`
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes_J�no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (1 .G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP ,
2.1 Owneri of Recor M "
I�aame(Print Ci�7tat
�? 40-1--anJ Gig sag-s�si
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : /PndF drl,-/` 7-e-Z7
�.aS^P� rdlGi �P �orJF.
SECTIONA: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item OffictaliUse Only
Labor and Materials
1. Building $ L Building Permit Fee $ r ndicate how fee is determined:
❑ Standard}City/Town Application Fee
2.Electrical $ s
❑Total Protect Co'st_. (Item 6)xmnlnpher` x
3. Plumbing $ 2 Other Fees $ _ 1: 11"
4. Mechanical (HVAC) $ List.
5. Mechanical (Fire $
Suppression) Total All Fees: $ 'z
6. Total Project Cost: $ /
Check No Cbeck Amount -Cash Amount:
El Paid in Full ❑ Outstandmg BalaneeDue::: , 21
SECTION 5:'CONSTRUCTION SERVICES
5..1/1 Construction Supervisor License(CSL) /a 0 -4- o2 � ��t�o Da
l�G► (/� / V( DQ C x P
Name of CSL Holder /�
List CSL Type(see below) (,,, S
No. a— nd e � :,.Tyge , Descnpnon
U Unrestricted(Buildings u to 35,000 cu.R X
�N R Restricted 1&2 FamilyDwelling
City7pown, State,ZIP M Mason
ry
Ro—ofing Covering
WS Window and Siding
�� _ •-��� SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 RegiVk ed Hom/T��J�„provement Contractor(HIC)
/I � �� HIC Registration Number Expiration Date
C�HIompany Nam a IC Registrant Na
No.and Stpael Email address
ad 6?4!'2? o4c 978-j ?065
City/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 ..........Xr No---.... ❑
SECTION 7a: OWNER AUTHORIZATIONTO BE COMPLETEI)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
r SECTION 7b: O WNER',OR AUT$ORIZED AGENT,DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
cory/ . d in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
""-NOTEs.
1. An Owner who obtains a building permit to do his/her own work,or an owner who hues 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.rnass govioca Information on the Construction Supervisor License can be found at www.mass.aovr_Tdns
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"
T
CITY OF S1�LEl�I, i�YASS.�ICHLSETTS
• BulwNG DEP:IRT.%MNT
N 130 WASHIINIGTON STREET,3a°FLOOR
TEL (978) 745-9595
F.cx(978) 740-9846
R D KI,{gFRi EY FY ISCOLL
MAYOR THOSLis ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BI:ILDNG COSLNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with 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
111, S 150A.
The debris will
be transported by:
( iDS/Q v( odl�i^�
(name of hau er)
The debris will be disposed of in
(name of facility)
(address of facility) -
/I
signature oP r aPP e licant
date
•1cNris�iGlx
CITY OF SM EN1, 2ANSSACHI SETTS
BuiwiNG DEPAR-r%lENT
oft 120 WASHINGTON STREET, 3'°FLOOR
8 TEL (978) 745-9595
FAx(978)740-9846
KI\(BERLEY DRISCOLL
MAYORTHObfAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/Ma-DING CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A n riicant Information Plc se Print Legibly
Name(Busincswrganizationtin ' idual): O
Address:
City/State/Zips�/��/�/ii //tg p Dl97C) phone#: 97957 -3 5-5' �6d7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with- 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑-0emolition
working for mein any capacity. workers'comp.insurance. 9, ❑ Building addition
[No workers•'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their ME]Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL t LEI Plumbing repairs or additions
myself.[No workers'comp. C. 152, Q 1(4),and we have no 12.❑ Roof repairs
insurance required.}t employees.[No workers' 13 ❑Other
comp. insurance required,]
•Any applicant dot ch�cke box AI must also fill out the section below showing their wwkm compensation policy information.
{ILtmcuwtuvs who submit this affidavit indicating they ate doing all work and then him outside contrctor must submit a new of idavit indicating such,
:Contraoton that check ibis box must anached an additiotud sheet showing the time of the subcontractors and their worker'ramp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below Is the pulley and Jab site
h1formatian.
Insurance Company Name: L r`Ptn f 2
Policy#or Self-ins. Lic. q: Expiration Date:
Job Site Address:�7 l !�^/)+ fC 7-6A - City/State/Zip• t� m4
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 25A of MGL c. 152ean lead to 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do lterebnll-I�A
d r„puins and pes uht !ef ojperjury that r/re iujurnrmion provfdeJ above is�true uudSiem nrS,(( �[�®_('jp Date• 13 //TL Ate- l
P o ,l;
OJjrcial use only. Do trot write in t/tls area,to be completed by city or town official
City or"town: Permit/1.1cense# _
Issuing Aulhorhy(circle one):
1.Board of Health 2.Building Department 3.Cityifown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.O titer—
Contact Person: . -Phone#:
VropowtfPage# of pages
,�
f 3 S— �oG
3 S
97U
Proposal Submitted To: 7� / Job Name Job#
/..I
Address 17 Job Location
Data
Date of Plans
Phone# - _ Fax#. Y a 4 s -. Architect
We hereby submit specifications and estimates for.
. u - -0 A,
-l^-
PAL 4,v—
We propose
//hereby to furnish material and labor—complete in accordance with the above specifications for the sum of:
$ (o Gl� J ` Dollars
with payments to be made as follows l S U r y X o g"t///
Any alteration o):deviation from above specifications involving extra costs will be Respectfully
executed only upon written order, and will become an extra charge over and submitted
above the estimate.All agreements contingent upon strikes,accidents,or delays -
beyond our control. Note—this proposal may be withdrawn by us if not accepted within days.
acceptance of J)ropool
The above prices,specifications and conditions are satisfactory and are Signature
hereby accepted.You are authorized to do the work as specified. _
Payments will be made as outlined above.
Date of Acceptance Signature
NC3819 MADE IN USA