12 COUSINS ST - BUILDING PERMIT APP (002) ��-► y -esg � � z � ry.
t
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
\� Massachusetts State Building Code,780 CMR Revised Mar 2011
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 Applied: CC 3 -0 — 1
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
S S .
1.1a 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 8) Frontage(fit) - 'd
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard 'n
Required Provided Required Provided Required Provi -<
fn
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: G
Zone: _ Outside Flood Zone' ste l dis osa al❑ On site? Municipal s
Public❑ Private❑ Check if yes❑ CA
m n
P p y -
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�axx 14 iJ9groor�7� k �e�P>� Sa160 A45S . 62197D
Name(Print) City,State,ZIP
>� ��r�%ns S�• 97� �yS �O
and Slreet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : r�
w 0 g z N irAcw 'Z A4
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building 5 oao.Oo 1. Building Permit Fee:S Indicate how fee is determined:
1 ❑Standard CityfFown Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5.Mechanical (Fire $
Su ression Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 15 1 C,uw- ❑Paid in Full ❑Outstanding Balance Due:
LXD
016 Q�?4sl � P
vnralLEIP
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) JOS/r� �L? 0�(0
G'�a, /A-S License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
Gi✓
No.and Street Type Description
U Unrestricted(Buildings up[0 35,000 cu.R.)
R Restricted I&2 Famil Dwcllin
City/Town,Stale,ZIP M Masonry
RC Roofing Covering
INS Window and Siding
SF Solid Fuel Burning Appliances
97N ?oy y7�1 Cect/ Cc�p I Insulation
Telephone Email address nn'I D Demolition q
5.2 Registered Home Improvement Contractor(HIC) 1 ,.74,gs / `O-3—.201
t r 141 PItefgr'� �.� HIC Registration Number Expiration Date
H1C ompany Name or HIC Reg s" trams Name l /
No. Str et cl2f- �J07� Email ad ess
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 Issuanc of the building permit.
Signed Affidavit Attached? Yes ..........W 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 L/.:L ��a
to act on my behalf,in all matters relative to work authorized by this building permit application.
MCIrk 1� d (Z zewskr 3 3 20(Y
Print Owner'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 application is true and accurate to the best of my knowledge and understanding.
k 3 3 12,P1
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/tier 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
«a•v;.mass.ao�/oca Information on the Construction Supervisor License can be found at ww v❑utss.eovhlp,
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"maybe substituted for"Total Project Cost"
' CITY OF &UENI, AXSSACHL'SETTS
BUILDING DEPAM.(ENT
a
120 WASHINGTON STREET,Sao FLOOR
'IIEL. (978)745-9595
F i x(978) 740-9846
KI\fBFRt F.Y DRISCOLL
"I Ma
:MAYOR �IOs ST.Pi'xvatt
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information \\ /n Please Print Leeibly
Name(Business,Organization/Individual): C�W CAfj0EN/ G((j�,, pp Y L L C -
Address: 2 _ l c- (,r(_ V ,nLM • /; p 2 �/ r/r/ r7
City/State/Zip:��JJE _ 1079• Phone#: 7 ( — J�7 — 0 / / /
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with 4. 0 1 am a general contractor and 1 6. 0 T�],ew construction
employees(full and/or part-time).* have hired the sub-contractors tT�et/
2.0 1 am a sole proprietor or partner- listed on the attached sheet.: 7. Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
workingfor me in an capacity. (workers'comp.insurance.
Y9. �Building addition
[No workers'comp. insurance 5. We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I I.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. LNo workers' 13.0 Other
comp. insurance required.]
Any applicant chat checks box AI must also till out the section below showing their aorkms'cromprnsadun policy information.
f I hwneowntfi who submit this affidavit indicating they am doing all work and then him outside contractors must submit a new affidavit indicating such
4"umractors that cheek this box must attached an additional sheet showing the norm of the sub-eummactn and their workers'comp.policy informadon.
I am an employer that is providing workers'coospensadon insurance jar my employees. Below is the pulley and job site
information.
Insurance Company Name:
Policy#or Snlf-ins. Lic.#: _ Expiration Date:
Job Site Address: City/State/Zip:
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. 132 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ul•thc DIA for insurance coverage verification.
I do hereby certyy under the palms a d penalties of perjury that the information provided above Is true(and correct
ImItire: - Date: 3-3 7
Phone d:
Ofcia/use only. Do not write in Ibis area,to be completed by city or town ojftchlit
City or"town: Permit)license
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other.
Contact Person:-_ _., Phone#: