41 COLUMBUS AVE - BUILDING INSPECTION (5) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 20!!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Appli : Oq o-$ 3 �y
av� t
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
perty Address: 1.2 Assessors Map&Parcel Numbers
1,1
(P�o C0LUHe /EVE
I.la Is this an accepted street?yes__X.,- 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 wnUerr of Record/•� / �r lCni, 1"4
(\I 114_l=sj�£Grt /\06�J/q� JCc 157/`7'
Name(P 'mt) City,State,ZIP
yi to /v,„ dvs ,�w 938'-2X9-a�51
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : b
- - Aecec%Ic.E !G S?'V
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ S' 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
^ Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ S 00 ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
4y4Z t_ License Number ( E pi ion ate
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
57 1 :70 R Restricted 1&2 Family Dwelling
City/Fown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
978 sZ819�1 "LL_I971eCC1*CA 7, I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC) (r(,4-M
-�C F k16n 1�t.-L HIC RegistrationNumber Expiration Date
HIC Company Name or HIC Registrant Name
I Lot 6�c 1+ �l.r
No.and Street Email address
S5A EW/ i 1t'JA 97� S7£4 /'}G
Cit /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 .......... ❑ 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 1/�-��� r /7�k//
to act on may jbehalf, in all p3ptters relative to work authorized by this building permit application.
�r
Print O er's Name(Electronic Signature) Date
SECTION 7b: OWNER' 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 appticatioo'is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Nam (E ectronic Signature) ate
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.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"
l
CITY OF S.UEM, �AxSS,ACHLSETTS r
• BuumLNr.DEPARTNmNT
+ 120 WASHINGTON STREET,Sae FLOOR -
�� TLC.. (978) 745-9595
FA.r(978) 740-9946
KI\fBF1tI EY DRI$COLL
MAYOR T1HOMAS ST.PIEM
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Leeibiv
Name IBusilustiorganizalion/lndividuall: f .0 d L-1 t cS>uST
Address: /l, t+ P� VF
City/State/Zip: '5 4G rz w , Alk. Phone#: q79 S79 /-46
Are you an employer?Cheek the appropriate box: Type of project(required):
I.IJ I am a employer with 4. 0 1 am a general contractor and 1 6. ❑ construction
constructionuction
employees(full and/or part-time).* have hired the sub-contractors ,�,/
2.0 1 am a sole proprietor or partner- listed on the attached sheet.: L�9 Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers comp. insurance S. 0 We are a corporation and its 10.❑Electrical repairs or additions
required.] of have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp.insurance required.]
•Any applicant that dtocks box#1 most also rill out the section below showing their wolken'wmpensatim policy information.
t I Inmwwum who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a trees affidavit indicating such.
:Contractors thst check this box must attached an additiond sheet showing tiro none of the sabcontrecicm and their wodoela'comp.policy inlema jim
l am an employer that it providing workers'compensation insurance for my employees. Below is fire policy and fob dice
information.
Insurance Company Name: i Pd&D U(2Foje6—
Policy 4 or Self ins. Lie.N:_ ��>••�L WC 42Q 10 l Expiration Date: I5? S
Job Site Address: 3�C_OGu/t�iQyl LAZC t 5�q66" City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration slate).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 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. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
l do hereby certify under the pains sad costlier of perjury that the information provided above is trr,e and comet
SiLniture7 r Date-
PhoncX G
0jfcial use only. Do not write in ribs area,lobe completed by city or Iowa ojfk iaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF S.0 Em. T%Lxss xCHUSETrs
Buuj:)LNG DEPIRTJIE.v'T
130 WASHINGTON STREET,3"FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
K[xfBERLEY DRISCOLL
MAYOR T Homs ST.Pl tilts
DIRECTOR OF PUBLIC PROPERTY/BI'ILONG CONMUSSIONER
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:
/No Sow
(name of hauler)
The debris will be disposed of in
Sio4�C40rivG
(name of facility)
(address of facility)
signature of permit applic �[
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