23 CLIFTON AVE - BUILDING INSPECTION (4) la .
The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
Massachusetts State Building Code 780 CMR T"edition OF SALEM
Revised Jonuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 200R
One-or rwo-Family Dwelling
This Sect' n For Official Use Only
Building Permit N mbe . Date Applied: v -ZA
,e V
Signature: —Wdk Ur-1 !�,� 1--a ( J
BuRknlgiromoilssioncAlns to f Buildings [)are
S CTION 1:SITE INFORMATION
1.1 Prope A 1.2 Assessors Map& Parcel Numbers
ress:
r� vrP;
—I.-la Is this an accepted street?yes lz no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) 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:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wneFt of Record:
7E -7! v� 3 C%i`�/v� �d stt���, MA
Name(Prin) Address for Service:
1 Si . 3it, 04-3/1
r
Telephone
ECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
f Proposed Work': �AJ *1 nd. .,.ss a Z
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression)
S Total All I Fees:
Check No. Check Amount: Cash Amount:
6. Total Project Cost: 5 f46 . L / paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Constt ction Supervisor(CSL) /DCLP/ar a / /
I.icense Number lizp lion I ate
Nam 1.- loldees y List CSL lype(see below)
T Descri lion
. JyMess t /�, �) U Unrestricted(up to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
" natnrc M Masonry Only
o- y S6 a RC Residential Rooting Covering
feI phone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 egbteT Noma Yfm roemeat Goatnct �AS
Ii1C an Name or/f�IIC Re istrant N• e -�R-e�giCs�ir Lion lumber
12 u /1 clay
-d/b
Address •spimlion Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
F
ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Ke&J 7 U,'C:L1 O/1 as Owner of the subject property hereby
to act on my behalf, in all matters
/authorized by this building permit application.
� -t//el`/Oer Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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.
Print N e
,QA �av �7 /Y rJ
Signature of Owner or Autrionzed Agent Date /
(Signed under the pains and penalties of 'u
NOTES:
I. 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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
2 When substantial work is planned,provide the information below:
Total Iloors 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"maybe substituted for"Total Project Cost"
of
Ccuiumer A"Vfvijlb ✓Gt!aaa i '�L,..ai hinrlh - U�p.li llnull tl'ul,l�, lrl• .
Office pf Consumer AfLnls& uslness Regulator I r lin:u'll nl If uildill� I;i ,ulaliuu uul `LI d.lrr
_ HOME IMPROVEMENT CONTRACTOR. Suoenrlsu
Registr
Expirati n: - 10/2011 License: CS 100210
163985
"ExpiraSipnr" 8/10/2011 Tr# 287680 Restnded[u: 00
Type.:,, Partnership -- t
ARSENAULT BRAS. CONSTRUCTION ERIC ARSENAULT
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ERIC ARaENAUI. 24 GRAHAM ST � �,• ; y ,
24 GRAHAM ST. LEOMINSTER, MA 01453
4F(JMINSTER MA:0145� " Undersecretary I .
Ezptr.nwn: 11/26/2011
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MOYNIHAN LUMBER OF BEVERLY, INC.
"QUALITY BACKED BYA DESIRE TO PLEASE"
82 River Street P.O. Box 509 FEIN:04-2261995
Beverly, MA 01 91 5-0509 A Contractor Reg No.:
978-927-0032 Hg Exp. Date:
Salesperson(s):
HOMEOWNER INFORMATION
Name Daytime Phone
o OP' Samei
Street Address(Not P.O.Box) Evening Phone
�/y�rep6K6 Al 0
�i06_n Mate Zip Code Mailing Address(rt different from Street Address)
_ WORK TO BE_PERFORMED_AND MATERIALS TO-BE-USED- -- - - -
Moynihan Lumber of Beverly, Inc. agrees to perform the work set forth in Exhibit A for Homeowner and to
use such materials in connection therewith as set forth also in Exhibit A, attached hereto and made a part
hereof.
The following schedule shall be adhered to unless pircumstances arise beyond Moynihan Lumber of
Beverly, Inc.'s control:Work scheduled to begin:/ /_ Expected date of completio /_/_
Ma be based u n arrival of al order material
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
Moynihan Lumber of Beverly, Inc. agrees to e o [n� work, and furnish the material and labor set forth in
Exhibit A for the Total Contract Price of: $ _ O (which amount includes all finance charges).
Payments shall
made by Homeowner according to the following payment schedule:
$%60 Initial deposit upon signing this Contract(the initial deposit shall not exceed the greater of
one-third (1/3)of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom
ty
j Ord�js s'et forth below).
/by_LLor upon completion of delivery of materials
$ y_// or upon completion of install
$ pon completion of the Contract
In order to meet the completion schedule set forth above, the following materials/equipme t ust pWpecial
ordered before the Contract work begins, for a Total Cost of Special/Custom Orders of$ n :
$ to be paid for building permit
$ to be paid for
$ to be paid for
DSO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Il
x1J.L✓ - _ •_'-- x 5/�9,�0 Moynihan Lumber of Beverf Inc. V/v III
Homeowner's Signature Data Contractor / Date
B : a�c/a� v 4��►C1 it�q�'
Homeowner's Name(Primed) Nam (Printed)and Title of Sofiatory
You may cancel this Contract If It has been signed by a party thereto at a place other than an address of
Contractor,which may be Its main office or branch thereof, provided you notify Contractor in writing at
Its main office or branch by ordinary mail posted, by telegram sent or by delivery,no later than midnight
of the third business day following the signing of this Contract. See attached notice of cancellation for
an explanation of this right.
1057-BEV 4/09 White-Office Yellow-Salestseivice Pink-Customer Page 1 of 5
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
AI: NIY1 ' Nlr 1'•1I
\I .1^4 11fJ \M II\6:,4�1�1Mk1•r •�.\I I\I,�1d�i.\� I11 J I ..:I't _
fFl:'l71-7.4M.'JMe! •1'.\X:'J71"43''/X46
Construction Debris Disposal Affidavit
(required fur all denwlition and renovation work)
In accordance with the siztlt edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54-.
Building Permit H . _ 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
1 11. S 150A.
The debris will be transported by:
1 name ut'haultr)
1'he debris will be disposed of in :
(n:uneut aci Ity /
taddrLm of facility)
-- — signature of 1%un it applicant
tt
CITY OF S.U.&Mv NLASSACHUSE-M
Bt:aDLVG D E7.hwmwr
120 \V.%SHc4GTOl1 STuirr. fie FLOOR
TEL (978)743.9"S
FAX(973) 7 IMSN
KIM®EA"Y C"COLL THONASST.PMUS
.UAYOIi DIRWMR Of(L SLlc r=p1lLTT/K MDLrc C0-%0 I5M%EA
Wurkgrs' Compensation Insurance Aflldavit. Ouil&rWContrsctorWEktctrkisnslPlRtneers
%JIMIC841 Informallaft
Vatne lyt,rr"MuOr{aariaaoanlrrkrtdtull:
Address: 4-=— L ejg l fit.
City/SdtdZiR Z,4aa j","S/r ry o/gSr Pitons M
Are roe to empbw Cheek the Appropriate bast Type orprsltld(regdrdR
I. 1 am a unpMygr wi V �. ❑ I am a Powell rasesrscbat ad 1 a Nar coommdon
etnplsrew(fWl aed/ge pssFias}• have hied the aokearsrsceoes T. erraooltlin
2. 1 am a Sala prspriater ter pawtaw lied m the aeaeltsd glnet= g
Ihip and have nit amplayea• Then w►sonnesom have I. Demolition
working for me in any cspU' "'odes'comp,Insamom 9. Q Building addition
i No workers•comp,insurance S. Q We am a ceapoirWge mod is I O.Q plocnical repairs a►sdditiorr
r quimiLl oaks haw onadad five
).Q 1 am s hoorosowoow doing ad work ,1(4� h�L I I.Q rhombing repair or addMors
myself.1Ye workers•comp, . 13% oo•l�wark� 12.Q Roof mpoin
insurance rpu7mdl r 11.0 Other
Comp,inumooe m4tinq
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r r6w"uwtaeg who submit tale aletia k wA eWe they on Jobs all wak see dos No aasoila more oos give sedans a am a1lFkek katenine r►
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in�irnrndeai
Insurance Company Name:
Yalicy, 0 for Sd(•iAL Lie.tit Eapivolles Date:
Iub Site Addrela: CityiStatdZipr
.tnacb a copy of tka worken'compoesstles Volley dealwalba pap(skawhtg Ike pocky ounber and stplrslNn daft)6
f ailun to aaetae coverap as"ited under Iectlae 2SA o(MOL a. 172 Can led to the imposirim of criminal ponalde ors
ring up to S1.900.00 and/or one-year imprisenmem,as well a civil penslrias in the fans a(a STOp WORK ORDER and a fine
.rf up to S:r0.00 a day"pint the violator. 11e&,M.*W(hall cupy u(this eatamme maybe furwrarded to the 017Ice of
I nv..tita"iung of ilia nIA for insurance covcrap wnrkaliaa
/Ja hereby to /y atnlll thaYAi rah"g1/or'y haw rb infMatedow pno+Anl ul/cer ' Irw ewreA
tL IGIIe:.� d
P• i J,
Offfr d vj*d,0I* De nor writs he thig arrq to rr•utw0%M!r rirj•W narw".//ln•in(
City or ruwg: Yrrmfe/Lleenrsd__
Isaa"nS.\vthonly (circle anq:
I Merril of Ilraltk 1. Hudding 1)vparrmunt ). Cior/town Clerk t. Electrical lmpecior 9. Plumbing Impactor
6. Uthtr
l..,nract I'ertan: _ Phone S.