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10 CRESCENT DRIVE - BPA-13-211 14 kii9(o $Y The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards Massachusetts State Building Code, 780 CNIR SALEM : Revised�Wnr 201 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: lbate,Appf4 Building Official(Print Name) Signature SECTION 1:.SITE INFORtVIATION I.1 P/D rGPJJr tssT ST 1.2 Assessors Map& Parcel Numbers I.I a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Propos dPrupus d Usk— Lot Area(sq It) 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION2: PROPERTYOWNERSHIP`' 2.1 Owner[of Re��..ggrd: L Low./J' Y� eZlZ9 R 1 - ;Xl ii, 4V,57 Q/r ?o iT�me(Print)7 City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work'': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ 4,1'.:5257y I. Building Permit Fee: S Indicate how fee is determined: Electrical �. ❑.Standard City/TownApplicationFee- $ - - ❑Total Project Cosh([tem 6)x.multiplier x 3. Plumbing S 2. Other Fees: S 4. Nlechanical (HVAC) S List:. 5. iNlechanical (Fire $ Su pression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost. $ 63drj 0paid in Full —0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Cu tstrucctmn Supervisor Li�ceense(CSL) �.����� �/�!L%`�a1D License NumT tier — Expiration Date Name of CSL Holder /� List CSI-Type(see below) /z- '� No.and Street Type Description /f -U Unrestricted(Buildings up to 35,000 cu. It.) if e/IJ /�Z. 4ZI C -7 R Restricted 1&2 Family Dwelling Cityyfrr n,State,ZIP ,,.+ M Nlason 1 GG�iwi-( 1� RC WindRootow Covering Sin WS Window and Sidin SFSolid Fuel Burning Appliances 5. ��- 7s! -�J1`-rT I Insulation Tele hone Email address D Demolition /.2j.RegisteeredHome Improvement Son�tractor(HIC) ! Ay F-r-1— 9 �3 /l!/L7�hO tl",p,y (f /1• leY HIC Registration Number Expiration Date HIC omev�ry /nr f IC� rant Name No. Street Email address C,- - a/9--o y'96-775--C)srf Cit /Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSAT[ON:INSURANCE AFFIDAVIT(M.G.L.e.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 1, as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZEDAGENTDECLARATION- 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. 4T-�X/ g l/_ ?- 1 �� Print Owner or Authorized Agents me(Ele tronic Signature) Date 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(111C) Program),will not have access to the arbitration program or guaranty fund under NI.G.L.o, 142A.Other important information on the HIC Program can be found at www.mass.,ov'oca Information on the Construction Supervisor License can be found at www.111ais.gov/dys 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. It.) 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" 5 . CITY OF S'kLEm) INWSACHUSETTS BUimt:NG DEPA&-I-.% YT • 120 W.{SHLNc;TON STREET, 3" FLOOR �d�o� TEL (978) 745-9595 FAx(978) 740-9846 KI,fgFRt >=F-Y DRTSCOLL MAYOR THo.%us ST.Pwjum DIRECTOR OF PUBLIC PROPERTY/BUILDL\G.CO%L%IISSIONER 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: (name of hauler) The debriss will be disposed of in - (name of facility) (address of facility) signature of permit applicant date dcbri5ai(dx HIC # 126.356 ®CD C01011p 3suilberS> 31110. 13 SEWALL STREET i PEABODY, MA 01960 ' ,,,Rr �,r•' OFFICE: 978-922-6120 SPECIFICATION SHEET Hone Phoue: • . Q fJ..... . Owners Name . . � Work Phone: . . . . . . . . . . . . . . . . y�. . . . . . . . . . . ��. ✓J!!. . . . . . . . . City State . . . . . . . . . Zip . . . . . . . . . JobAddress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . SIDING 1.Siding Tipe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Width . . . . . . . . . . . . Color. . . . . . . . . . . . . . . . 2.Area to be in House . . . . . . . . . . . . . Breezeway . . . . . . . . . . . . . Garage . . . . . . . . . . . . . Additions . . . . . _ . . . . . Dormers . . . . . . . . . . . . . . . . . . . . . . . . . . . Other. . . . . . . . . . . . . . . . . . . . . . . . . . . 3.hisulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Trim:cover Ll Yes Ll No Color. . . . . . . . . . . . . . . . . . m to be done: Soffits . . . . . . . . . . . . Fascia . . . . . . . . . . . . . . Rakes . . . . . . . . . . . . . . . . . . . . . . . Ceilings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Window and Door Frames . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . 6.Gutters and spouts ❑ No Use heavy gauge seamless . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r. . . . . . . . . . 7.Shutters No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. W ws and.Doors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ROOFING / Material Type �, <,�J . a . r . , Color. . . . . . . . . . . . . . . . . . . . . . . . �s�'%.L . . . . . . . Areas to be done . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .�: . . . . . . . . . . . . . . . . . Remove existing shingles 8,/]�'es ❑N,o/ 15/b.felt. . . . . . . /./. . . . . . . . . Metal Edging . . . . . . . . . . . . . . . . . . . . . . Chinutev and vents, etc. .l /4/i.�/Ju--e'� G/ !rr'. • . . . . . . . . . . . . . . . . . . NOTES. . . yr�/fZ II.: �s . . .....GPC�G. Gn pd�/� . . . . . . .. . . . . .�o /.1.. . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ._ . . . . . . . . . . . . . . . . . . . . . . �J�j a0 $. . . . . . .Deposit Material and labor to cost$. .G.CJ.tom�J :. . . . . . . . . . . . . . .payable as follows: $. . . . . . . . . . . . .ist Installment DO NOT SIGN THIS DOCUMENT IF THERE ARE ANY BLANK SPACES. $ a�' .2nd Installment $. . . . . . . . . . . . .Balance on completion Contructor will do all.said work in a good workmanship manner. You niay cancel this agreement if it has been consummated by apart),thereto at a place other than an address of the seller, schich may he his main office or brunch thereof,provided you notifit the seller in writing at his main office or branch by ordinan,mail posted, by telegram sent or by delivery,not later than midnight of the third business Aar following the signing of this agreement. IN WITNESS THEREOF, the parties have hereunto signed their names this. . . . . . . . . . . 1��. . . . . . .dav nf. " ' 7 ' " " . . . 20.1d. Accepted: ' Signedtry/�..,�/ . . . . . . . . tJ//n signed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Owner Per. . . . . . . . . . . . . . . . . . . . . Represe tative Authorised Rep. . . . . . . . . . . . . . . . . . . . . . . . . . . . Strikes, labor disputes, imrlemem taathec or material supplier delo.is resulting in work stoppage are hecond the control of the compam•. CITY OF S.u.Em, lLNSSACHUSEM ©UMDLNG DEPAR—M&NT 120%V.1SH ,NGTON STREET,3"FLOOR TEL (978) 745-9595 Fkxx(978) 740-98.16 KIJIBERi EEY DRISCOLL _ 'IHOaL►SST.PMRRB MAYOR DIRECTO R OF PUBLIC PRO PERTY/BIaIDL`IG COJLUISSION ER Workers' Compensation Insurance AtTidavit: Builders!ContractorvLElecfr[ciann/Plumbers Applicant information Please Print Legibly V.tlnt:(nusin�,rOr�ni:atiorvindividual): /Jdg�L4��o ��7i Pw (_-d 5���+Cy Address: biv.Srit/r s� city/Statelzip: .41jloe-or 4,F17 Phone hl: _ S Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer wide 4, ❑ I am a general contractor and 1 6• employees(full and/or part-time).* have hind the sub-contractors ❑Now consuvction 2.p[1 ain a sole proprietor or partner. listed on that attached sheet t 7• ❑Remodeling ship and have no employees These subcontractors have V. ❑ Demolition working.fur me in any capacity. workers'camp.insurance. 9• E] Building addition (No workers'comp.insurance S.'[3 We are a corporation and its required] ofOcers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeuwnur doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,i(1(4),and we have no 12JE�_Roof repairs insurance required.]t employees.[No workers' comp:insursecerequired.]. 13.C1 Other •Any appllc:ue chat chtxtas basest must alar fill oua the sedion below Showing their"it=*compensation policy in(nmmion r 1 hxnauwnen whd Submit this affidavit indleming they aro doing all work and then hlie eutsidecontmcteq must submit a"aindovit indicting Such. �Comraeturs that chcsk this box coma lunched an aedllfunal ghee!Showing rho none of iho Subcontractors and their works eo romp.puQey infotmanon. I One an employer that Isproviding workers'compensadon htsurancerfor my employees', Below Is roe pollcy and Job site brfornrudom Insurance Company Name: /`✓1 `y//' �y�1 Policy U or Self-itis.Lic. N: 1,�7, 76) 1 r01 e/Z Expiration Date: —/y Jub Site Address: 10 `-+t eize,7`- J" City/Statr/Zip�� /'/1 ,/ , O/'Q ryp ,lttacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failur¢to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 und/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a tine of up ro SM.00 a day against ilia violator. Ile advised that a copy of thisstatcment may bo rurwarded to the Mice of (nvestigutiuns of th¢D!A for insurance covcrag¢vurilicativa Ida hereby certify oder dto alnar and penalties of'erfu that the iuJunnullon rovided above is true urrd correct. c � p Siennure: _ Oats• y �� r)jj1c1a1us,,anJy, no not write br Ih r arra,to be completed by city at town a/fk•Ial. i City or town: ..... Permit/l.lccnse.;t Issuing,%ulhurity(circle one): 1. Gourd of Ilealth Z. iluildinq Oopartnium 3.Cityi town Clerk I. Elactrlcal rtupectur i. Plumbing Inspector 6. Other .-- __-- Contact Person: _ ... _ ...__ ._. Phone tk I