3 COUSINS ST - BUILDING PERMIT APP 1 I z `7 -7 5 Lf �Zo3
The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEIVED CITY OF
Massachusetts State Building Code, 780 ClIMPECTIONAL S RVIC€kEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a p 3
One-or Two-Family Dwelling �4 AUG 'y
This Section For Official Use Only t
Building Permit Number: Date Applied:
'Ll'
Building Official(Print Name) Signature ` e
SECTION 1:SITE INFORMATION
1.1 Propert;Address: 1.2 Assessors Map&Parcel Numbers
J C014sws Sr
L l a 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 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 B"', Private❑ Zone: _ Outside Flood Zone? Municipal-[210n site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow 'of Record:
err�s,�>✓ lJ��r� _ See&1 n'1 or97a
Name(Print) City,State,ZIP
3 Co,csws Sr _ � 8F91 0Y
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.ElNumber of Units Other ❑ Specify:
Brief Description of Proposed Work': jP7jjlctjS &T- UJaJ(,. 64416V C>
F v1SN/✓(' SYSt r 22s 2X2 fJ/yP CF_iui✓G- FINIJtl &;'7 '2'' fldo«L
TU �C G(SLSC1 /S^S �l9 �/1rM/L,y /`1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building Z _ $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ yt
4.Mechanical (HVAC) $ List:_
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 2 7 3zf 11 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
Y0 _5ff&n4 H v1 A. List CSL Type(see below)
No.and Street "'t Ptda Type Description
Zr U Unrestricted Buildin s u to 35,000
'�y�O�' i•t R Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Maso
RC Romiin Coverin
WS Window and Sid'--
SF/ ./}./�, SF Solid Fuel Burning Appliances
W1M15% y7 due, ^ ��C �J " '�n• I Insulation
Telephone Email address D Demolition
5.2 R isr ere&5omg Impr em e6Cgptractor(HIC) /
HI Com Name or HICA�strpnt Name
HIC Registration Number Expiration Date
No.and^&eetn VJ M� G/2�j
Email address
City/Town,State,ZIP Tele hone
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 IssuancSwf 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 �N/�J t/AZr✓1I/Z-
to act on my behalf,in all in
relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By enterr gm i name below,I hereby attest under the pains and penalties of perjury that all of the information
cont 'rfed in/t`�is a is ion is true and accurate to the best of my knowledge and understanding.
//''
Tint er's or Authorized Agent's Name(Electronic 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/dos
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"
:vb CITY OF SALEM, MASSACHUSEM
rI BUILDING DEPARTMENT
V�\�� ` r ✓ ��� 120 WASHINGTONSTREET,3" FLOOR
\�ma TEL. (978) 745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COIVMSSIONER
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 c40, S 54; Building Permit #_ 0 -114-4J601 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
CCkrq0a,.,-,
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
a- qo
CITY OE Si` ZM, NL1SSACHUSETTS
Buid-DING DEPART>tE-\T
3120 W.is NGTON STREET, 3aa F100R
TEL. (978) 745-9595
F.�x(978) 7.10-9846
KI\lBE1LL.EY DRISC0f1.
"-,'LA'YOR T HOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO',L\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PtUmbers
A t slicant Information //� // Please Prfnt Le ibi
N Intl:(flusinuss Org,miraliom'Individuat): r9,, /-s
Address: � 9 5WAk)w pe.1
City/State/Zip: 6tm7w eA 07a"Phone11:_
Arc n employer.,Cho k the appropriate box: F6. []
oject(required):
I. 1 am a employer with 4. ❑ I am a general contractor and t
employees(full and/or part-time).' have hired the sub-contractors dnswceton2.❑ Iam a sole proprietor or partner. listed on the attachedsheet. t odelingship and have no employees These sub-contractors have olitionworking Misr me in any capacity. worlcvrs'camp.insurance. ding additioniNo warken'camp. insurance 5. ❑ We are a corporation tad iUrequired.) officers have exercised their . trical repairs or additions
3.❑ I ant a homeowner doing all work right of exemption par MGL I l.❑ Plumbing repairs or additions
myself. (\'o workers'comp. C. 152, §1(4),and we have no 12.❑ Roof mpairs
insurance required.) t empluyees. (No workers' I3.0 Other
camp. insurance required,)
•any upplictvn nut checks aux a I most also fill 4)u1 the section bylaw ahowinu their workcn'eompenudon policy i"Amnattun.
'I lumenwnvr.who suhn,4 this»nsinvil indiulins thcy un doing all work and then him outside contractors most suhmit a new amdavii indimliny such.
$'�nnmvroo thus chvmit this box most anaahal sn addolurctl:hml shuwimu the nune of the subaonrncion and that,waken'comp.policy infonwlion.
1 ant an employer that is pruvidbig workers'compensation insurance for my earpluyers. lfeluty is the policy and fob rile
inforinulian.
Insurance Company Name: `'�/ .--- �` tom_
Policy it or Self-ins. Lie. a: (vVU� '7 2 O 7/ S� E-Z y 4.5
�J Expiration Date:_ ,y�
Job Site Address: J 64sws �� City/Slate/Zip: _3/�� i/r`/ aq;�Q
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. 152 can lead to the imposition of criminal penalties of a
tine up to SI,300.00 and/or one-year imprisomacm,as well us civil penalties in thu form of a STOP WORK ORDER and a line
orup to S230 00 a day against the violamr. Ile advised that a copy of Ihis ntalement may be 1-unvarded tothe Office of
Imesligotiuns r IA for insurance coverage verification.
l du here y c•en'y r the pains and penaldrs cf perjury that the infunnution provided above is true and correct.
Si••n t re' �� ��
Untd:
it '
D//icial use anly. Do not write in this area, to be completed by city ut totvn o/Jiviu2
City nr l'ulva: _ _ Permidl.ieensc p
Bluing Autitnrify (circle one): -' --- ._---.. _—_
1. Board of ileaith 2. Buildln;, Bepariniew .i.Ciiylfuwa Clerk J. Electrical hupcctor S. Plonibing Inspector I
h. Other .. _.. ...
Com:ict I'vnnn: Ph, tt:
Office o �onsumers �n�ess e�n
i-�U9 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvelrt Contractor Registration
Registration: 137943
Type: Supplement Card
OWENS CORNING BASEMENT FI,�I'=:kd�> �— Expiration: 1/29/2015
DANIEL WALSH a
60 SHAWMUT RD
CANTON, MA 02021
Update Address and return card.Mark reason for change.
SCA 1 0 20M-05/11 Address ❑ Renewal ❑ Employment Lost Card
�. _ �e�0ommcoau(,eo,�c o��luaaac�cuaella
ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only
WExpirati
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
k.,�, Office of Consumer Affairs and Business Regulation
egistration:._jType. 10 Park Plaza-Suite 5170
p /29/2015_j4 Supplementard Boston,MA 02116
..
OWENS CORNING"BIgS M NT FINISHING SYS
DANIEL WALSH 'tr
60 SHAWMUT RD
a—
CANTON,MA 02021 Undersecretary Not valid without signature
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards -�
Construction Supervisor 6
License: CS-079893 Oil
DANIEL FWALSIf
488 KENDALL RA -
TEWKSBURY WA 0Qj
-
`s
J.�.... ,d ...)110 Expiration
Commissioner 10/05/2015
� I
O'Connell, Bridget
Douglas,Stephen
3 Cousins St
Salem, MA 01970
508-843-0454
508-843-0345
CONTRACT Customer Name_Stu-im Zc,'(3s � dcv /.1f(an Customer Signatur
SKETCH Contract Date -7— 2z I Sales Representative Signature_411
ATTACHMENT Customer Phone 5.60 - 443 -04..5W 5'011_+t413-csw5' Contract Price 79Z1;
P 9 6 Z :0 IS 30 Tj M SS M S] A T ]� 35 b ]> 9B JB fB �B 59 5� 5] 9 W Y Y 5] SB 6B SB:. ✓/
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'NOTES: �: F vo. �,.. FrEaclsa.otatei.,na.1s one foot unless oth.W15 noted.This sketch is a good..faith
thework to be tlone,It is untlerstootlhat all dimenionsed from this sketch are approximate,and that all locationsofoutletsghtres,plugs,lacks and/or switches are subject to change it necessary.