13 EVERETT RD - BUILDING JACKET 'file Commomvealth of Massachusetts imsPECTIOk L S R YICE
` v Board of Building Regulations and Standards CITY
SAL OF
I
Massachusetts State Building Code,780 CMR„ r; Retake#$40711
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling 1
This Section For Official Use Onl
Date Applied-
Building Permit Number: PP
I Si ature._ Date
Duilding OfBciai(Print Name) 6!t - _ .
SECTION 1;SITE INFORMATION
FBuilding
ddre 1.2 Assessors Map&Parcel Numbers
cce ted streetT yes no Map Number Parcel Number
ormation: 1.4 Property Dimensions:
Proposed Use - Lol Area(sq R) Frontage(R) -
1
1. BBuildingSetbacks(R) .
FPrivate
. . Side Yams .. Rear Yard"
i2eyuiredProvided Required - Provided. Required" - Provided
1.6 Water SG.L c.40,§54) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Public Zone: _ Outside Flood ZoneT Municipal O On site disposal system" ❑"
Check if E3
SECTION 2: .PROPER FY OWNERSRIP!'
2.1 O nerr of Record
%�oNf}[t� �2flt2NfGc ' lip
.IN)me(Print) City,State,ZIP ,
3v�,�e1'T 9�� �aa 67s!� PN/r2A�P aa��9mi4ic
No.and Street - Telephone• ' Email Addass
SECTION 3:DESCRIPTION OF PROPOSED WORIC'(check all that apply);
NewConstnmtion ExistmgBuilding Owner-Occupied 13"1 Repairs(s) Alteration(s) O Addition O
Demolition Accessory Bldg.❑ 1 Number of Units—_ Other 13 Speciiyt
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
It Labor and Materials - " ^-
1. Do ding $ pZ.O O O O" 1. Building Permit Fee:$" Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S Cl Total Project Cost'(Itern 6)x multiplier x
J. Plumbing 5 (J 2`?Pther Fees: $
4.blcchanical (FIVAC) S Q List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:
6.Tutai Project Cost: .S 13 Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C 5 d 0 3.�-7 j
f i flee )j ( .L r(."l? eVC h Z h Pf License Number Expiration Uate
Nane ofCSL Holder List CSL'rype(see below) C>
Y Ceh Met e L- Type Description .
No.and Street
U UnnSuiclnl(Buildings tip to 35,000 cu. It.)
� �'f''CA- �! 93 R Restricted I&2 Family Dwelling C. Co Uir t�9 -
6ty/Ibwn,State,ZIP M Masonry -
RC Roofing Covering
WS Window and Siding _
SF - Solid Fuel Burning Appliances
6 1 Insulation
Telephone Email address D Demolition
5.2 Ategistered Home Improvement Contractor(HIC)
/"C'cle eh Z.h EV HIC Registration Number Expiration Date
i IIC Company Name or HIC Registrant Name
Email address
Citvrrown.State ZIP Tele hone
SECTION&WORKERS'.COMPENSATION 1NSURANCE AFBIDAVIT(M.G,I a 152.§ 2$C(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 Isluance of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
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 .Xlq� /
tg act on my behalf,in all matters relative to work authorized by this building permit application.
K cc c,en2heri X *11X11,6
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contat d in this application is true and accurate to the best of my knowledge and understanding.
x 10A4D 9A�Ncj1
Print Owner's or,% mrizcJ r\genl's Nnme(Elccuomc Stgtmture) DuIC
NOTES:-
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
--(not revered in the Home.lmprovement Contractor(HIC) Progmm)i will uo have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other importnn[information on HICTrogram can be Totten: at —--
ww+v mass eov'oca information on the Construction Supervisor License can be.found at www.ntas�
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. ft.) N (including garage, finished basementlattics,decks or porch)
-Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'rype of heating system Number of decks/porches
'rypeorcoolingsystem Enclosed Open
3. "Total Project Square Footage may be substituted for"Total Project Cost"
f -
M\ The Commomrralth of Massachusetts I t )I:
t Board of 13w1ding Regulations :u)d Standards blt It'll' 11.f11
9 Massachusetts State Building Code, 780 CNIR. 7°i edition s`I:
1uiIding Permit Application To Construct. Repair. Renovate Or Demolish a Rcrur,/J,nn, u r
One- or Toro-Fumih, Dtrt'llin,S :ooS
' is Section For Official Use Only
Building Permit Number. Date Applied:
siumatule:
VVV� Building commissioner hpeclur or Bun dings Date
SECTION I: SITE INFORMATION
1.1 Property :'ddress: 1.2 .Assessors Map & Parcel Numbers
I. btu la In this an accepted street? yes_ no P Number P:acel Number .
1.3 Zoning Information: 1.4 Property Dimensions:
v
Zoning District Proposed Use Lot Area 1sq 11) Frontage of I .
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Pro%lded
1.6 Water Supply: (M.G.Lc. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone:' ,Municipal ❑ On site disposal rystcm ❑
Public❑ Private❑ Check if yes
SECTION 2: PROPERTY OWNERSHIP[
2.1 Ov nert or Record• �� /,,�P`yP J1 /J�/
r A. / / i1
Nmne r t Address for Service:
1 'fgri_urea
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKz(check all that apply)
Nev Construction ❑ E� Owner-Occupied ❑ Repai rslsl ❑ Alteration(s) \Jdition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_- Other ❑ Specify:
Brief Description of Proposed Work': L £ O
%nsfr// f e s
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Uzm . (Labor and Materials)
L Building $ 30�. Qb I. Building Permit Fee: 3 Indicate horsy fee is dcterm..
❑ Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost (Item 6) z multiplier x
i
1. Plumbing S 2. Other Fees: S -
List:
4. ,btcchanical (HVAC) S
5. Mechanical (Fire , -_-
5 Total All Fees: S
Su . ression)
� Check No. —Check :\mount: Cash :\nuou
uun:__.-._
j b. Total Project Cost: S 93QQ, QQ ❑ Paid inFull ❑ Outstanding Bal:mce Due:—_
it �I
SECTION 5: CONSTRUCTION SERVICES / � t r
5.1 Licensed Construction Supervisor (CSL) 5-77,33 -5� 6 /l'Q
l t License Numhcr 1-4)1maroill Dato
Nance of C'SL- I folder '
1� C.�,_Ye 5 raI e — l.ut CSL'I\pe ace helu�ol --
\ddress � 1 c e D............nro
L t'nrestoc icd n�i to 34.000 Cu. 1=1.
R Restricted I.@'_ F:uml� Ds�cllu)e
.Signaut-t t\ /� N9 Nlasonn lAtly
ResiJential Roofing('u%cnng
Telrphane ! �," \1'5 . Itr>iJrnual \t niJu�� cud .iidme -
i • S1= Rr,idemiul Solid h.iel liuminu \ i)h:urcc 111a.dlJIl -11
D Readential Demolition
5.7 Regi�tered Ilome Improvement Contractor (IIIC) 1 O)�a4
i� Sesvlr nSt, =nr --
HIC Company Name or/'HIC R•gistrant Name Regisu aeon Numher _
Maio
Add •, (q 1817�11 -D1I��J
Es r nun Dale
(�Signatur Teleph> me
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
1. Y as Owner of the subject property hereby
authorize r-z1A to act on my behalf, in all matters
relative t w k auth(�iz y t, is b ildinv permit application.
� 4�� f
si, to o \liner rrDme)
S N 7b: OWNER` OR AUTHORIZED AGENT DECLARATION
1, ( `n[ 15�r Ke r Zr)rz.0 , 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.
rZ
Maranty
er-or_Authorized-Agent)he ains and enalties of er'u )
NOTES:
r who obtains a building permit to do his/her own work, or an owner who hires an unregistered comuaaur
tered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
r guaranty fund under M.G.L. c. 1-t2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL) can be found in 780 C'MR Regulations I I0.R6 and 110.R5, respectively.
'. When substantial work is planned:provide the information below:
Total flours area +Sq. Ft.) (including garage, finished hasement/autics, decks or poichi -
1 Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedroom.,
Number of bathrooms Number of halt7hwhs
fvpeot heating system Numberotde�ks/p�rchc-s
'f}'pe of coulioe system Enclosed ()pen
3. 'Total Project Square Footage- may be substituted for "Total Project Cost-
J
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of M. G. L. c. 40, Sec. 54, a condition of
Building Permit Number is that the debris resulting from this work shall
be disposed of in a properly licensed facility as defined.by M. G. L. c. 111, 'Sec.
150a.
The debris will be disposed at: Salem Transfer Station
owned by Northside Carting
Mign_atu_-of rmitApplicant_�
a/v/�)9
Date
Christopher Zorzy
Name of Permit Applicant
A & A Services, Inc
Firm Name
115 North Street. Salem MA 01970
Address, City, State, Zip Code
CITY OF SALEM
3, ) PUBLIC PROPRERTY
DEPARTMENT
n,�lltl !U I 1 I�N lit „1 I
'N I_' \C.\.I link,11�NSIitII1 • S.\If
1'! [: `)'J-,4i-9i'Yi • F
Workers' Compensation Insurance Af idacit: Builders/Contractors/ElectriciansiPlumbers
1 ilit-ant Information Plcase Print I evib1Y
Nalllc tl3u,mc,s ()r_anlcuntn lndntdtwll: Ae A
Address: 115 Nor+h S-h C -
City,State Zip:�� M� C�I�i 7C� phone #: ( `17S)
Are %on an employer:' Check the appropriate box: - Type of project (required):
1. I am a employer with ❑
4. ❑ 1 am a general contractor and 1 New construction
tJ � 6.
employees(full andur art-time).' have hired the sub-contractors
p' 7. ❑ Remodeling
listed on the attached sheet. i
❑ I and a sole proprietor or partner- g. ❑ Demolition
ship and have no employees These sub-contractors have
working for the in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
required.) officers have exercised their
right of per MGL 11.0 Plumbing repairs or additions
3.❑ I am a homeowner doing all work b exemption Pon p
myself. [No workers' comp. C. 152, §I(4), and we have no 12.❑ Roof repairs
insurance required.] r employees. [No workers' I3.0 Other
comp. insurance required.]
•Uy applicant that checks box HI most also till out the section below showing their workers'compensation policy information.
' I lumeuwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
C ntrocnrrs than check this box must attached an additional sheet showing the name of the sub-cuntractors and their workers'comp. policy information.
/con an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
A Trc4�/6o� f2
Insurance Company Name: ' �Lt� 4 E q
Policy # or Self-ins. Lic. #:�y_'�y4�u tj JDI /S U 13 Expiration Date: ]U�t{' -(/�
Job Site Address:/ �/ / /�t� City/State/Zip: P/ / 1 / /
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 MA of tbIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a fine
of up to S250.110 a day against die violator. Be advised that a copy of this statement may be tonvardad to the Office of
In\eslie:uians of the MA for insurance co\erage vcrificalion.
/Ju hereby ter `at der the pains and pens ties of perjury that the information provided above is true and correct
I IVIII Date:
eV
011icial use only. Do not vrite in this area, to be conipleted by city or town officiaL
City or Foan' #--------..---------
Issuing Authority (circle ( ne):
1. Board of Ilealth 2. Building Department 3. City/fawn Clerk 4. Electrical Inspector 5, Plumbing Inspector
6. Other
Contact Person: ---__—._ —_ Phone #:—
1
Information and Instructions
\las,achusctts General Laws chapter 1 5' rcquocS-all cmplo�crs to proN ide workers' compensation for their employees.
I'tu suant to this statute. ,in rrnpluree is defined as -- c%en pet:Son in the scn ice of.naoher under any contract of hire,
c y,ress or implied, oral or �%nnen."
.\n emplorer is defined as "an indi�tdual, p,rnr•crship. .t;socation, corporation or other Icgal entity. or any two or more
, (the firrcoing engaged in ajoint enterprise, and including the legal rcpresentatises of a deceased employer, or the
iced%cr or trustee of an individual, partnerxhip. .association or other legal entity, employing employees. I loweser the
Wa ner of if dwelling house having not more than three aparnnenCs and who resides therein, or the occupant of the
Jet cuing house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building: appurtenant thereto shall not because of such employ ment be deemed to be an employer." _
\1(iL chapter 152, ¢2506) also states that '-evcry state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
'applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.Wdltionally.'NIGL chapter 152, i25C(7) states"Neither the commonwealth nor any of itspolitical subdivisions shall
cuter into any contract for the performance of public cork until acceptable e%idence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers'.compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' -
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permivlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pemtivlicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The ()ifice of Im estigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us call
the Dcpu intent'S address, telephone and ta.c number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofllce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Rc�t>eJ �-'6-OS
Fax # 617-727-7749
www.mass.gov/dia
72.'fOom//1K19CIlM, a o�✓{'LOddQC-wa
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 57733
,. EfctFd'a3e,•=_5/26/1958
rExgf 0ny26Y2009 Tr# 13739
13
CHRISTOPHERZA ' � ? '
115 NORTH ST
SALEM,MA 01970' Commissioner
_ _ . � _.. ✓ire �o�ld �,�aeaacluee�
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Ezpirati0n 5/261201.0 Tr# 267870
Type:_Private Corporation
A&A SERVICES.JNC� -
Christopher Z0 ---ej—
115 North Street
' - Salem,MA 01970 `" Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Lava M.Marfm,Commw over Wa
Deleader-Contractor
CHRISTOPHER ZORZY
Eft.Date 040 .�
Exp.Date 04/08/09
8/09
DC000440
BO
emheroffI C.OII..IKEIIIS.T. IIII��_II ��IIIII IIII 9 i §;
_ I II IIIO IIlu ulO�III�uIOf�ll6@I�u l�l�I eOSTON-RENEW
:- SUNRISE Look
WINDOWS®
The Difference is Clear l NFRC Label
The National Fenestration Rating a
Council's (NFRC) Energy Performance wnyl Ernw d.00ve Galaz0.kgon Fill
Ulba U Put Warm Edge 5yace,
_ label is designed to help consumers R ea n,:Ve ecag9l dseee
CITY MPG HWY MPG ftaua Number
2 6 3 3 measure and compare the energy ENERGY PERFORMANCE RATINGS
performance of different window LLFactor"'S.A-M I SalarneatGaIneoefadet
brands. Just as the EPA sticker on a 0.31 1 0.37
ADDITIONAL PERFORMANCE RATINGS
alMllse,ewe"g Met,elfians,dd„n,cendro,.,, new car will give you a guideline to the YaudeTansmmanm Nr Leakage lUsnf
dteE,M1eWbenaveM1i wMHbro eY . RwNb d 0.54 0. 1
ro EPA lndlmle Mel the mejodry.veM1idea withh M iM1s..eae cam's fuel economy, the NFRC label on
aatlmelee vde aNiwe a.arean II aM 3a mp,in Me
dy aM aeay.,n and n nW an Me hitees, a window gives consistent ratings that o'Wen5atlOn Resrsidnce
The higher the gas mileage the bemtec can help consumers determine both 54
Winter and Summer perfomriance a
PN4V.vY se emabM►e..
characteristics. .p.YgkaaoLaa.a
' Actwl rest sampe.03 au leakage.
The Di(/erence is Clear.5.
CNFJ ' Summer
U FacQr_.., Sunrise Windows Solar Heat'Gain
Vinyl Extruded, Dual Glaze, Argon Fill ;Coefficient '
In the WINTER,the NationalFenesnaaon Ultra U Plus, Warm Edge Spacer ,.
lower a window's overall Raft Coundl v,(kS'HGQI ` •
Product Type: Vertical Slider
U value,the less heat Product Number 00037 In the St fNIAIER,,a
you will lose tI ou Iowei SHGCrmeansLess
_ that window. .owner ENERGY PERFORMANCE RATINGS solar radiation is Jruse less tmeansgv1; t l admit ed throu` you
saving you 6`
do
r(U.S✓I- Sddr Heat Gain Coe ii_ie-nt ` wind
our ow. Your home
more,since your furnace will remain cooler and
isn't running as much. 3 1 0 r not have
au conditioner will
to work as bard.
Visible ADDITIONAL PERFORMANCE RATINGS
Transmittance r islble Transmittanc ion
ge(U.S - i I:eaka
Visible Transmittance e'ower e'number,
(VT)measures how s S 1 the les§ wait
much light comes Condensation Resistance on The lowest
through a product. The number the government
higher the visible assigns is a.I and
transmittance,the less Sunrise Windows
5
tint there will be to the pi actually are even lower.
glass. A higher rate Manufacturer stipulates that these ratings conform to applicable NFRC procedures for detemmining whole Windows with an air
ensures a clearer piece product performance:NFRC ratings are determined for a fored set of environmental conditions and a leakage number
of glass. specific product sae.Consuh manufacturer's literature for other product performance information, above.3 fail this test.
www.nfrc.org
Actual test sample .03 air leakage.
f041107 SS7-V3
_L
The Commonwealth oftbiassachusetts R R (CES
Board of Building Regulations and StandtrR�CiB�AL $E C4d2011
I � Massachusetts State Building Code, 780 CI4IR 1.S
^^�� P �RZ e
Building Permit Application To Construct, Repair, Renovluvo lr;aAsh a
One-or Two-Family Dwelling
This Section For.Oflicial Useonly;
Building Permit Number. Date pltedf:
f1. Building ORicial(Print Name) " Signature_
SECTION 1:SITE INFORtHATION
1,l Property Address:
r 3 Fs? A . 1.2 Assessors Map&Parcel Numbers
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.d Pro ert `�Iingglonsr� `
Tuning District Proposed Use - Lot-Arm(sq n) ,Frontage(11)
1.5 Building Setbacks(R) "
Front Yard Side Yaids Rear Yard -
RequircJ Provided -Required Provided Required - Provided
1.6 Water Supply:M.G.I.c.40,§54) 1.7 Flood Zone Information- 1.8 Sewage Disposal System:
Public D Private D Zone: _ Outside Flood Zone? "
Check If csD.. ." Municipal 13 On site disposal system D
SECTION 3r PROPERTY:OWNERSHIP"
2.1 OtvAer'of I{ecprd: R G
K ah2/aL s G✓I
.N''me(Pnnt -City;State,ZIP - - -
V� "
No_'Street �TNep�ev�O6 Email AdJr�ss "
SECTION 3:DESCRIPTION OF PROPOSED VO RK check alt(- tba met jy)"-
New Construction D ExistingBuilding❑
g lhvner•Occapied ❑ ftepairs(s) ❑ A►terotion(s) O Addition ❑
Demolition D ActessoryBidg.❑ Number of Units Other D Specify:
Brief Description of Proposed Work,:
."
SECTION 4:ESTIMATED CONSTRUCTION COSTS' "
WC4jst: S
- Estimated Costs: Oflicirl Use OnlLabor and Materials) Y
ing S l f�f L Building Permit Fee:S Indicate how fee is determined:
ical S ❑Standard Cityfrown Application Fee-
D Total Project Cost'.(item 6)s multipliering s 2 QOterFees: S
nical (HVAC) S - List:nic:d (Fire Sion) Total A0 Fees:S
Prnject Cust: .S q r Check No.&&Check Amount:-Cash Amount:
Ol K� ' ❑Paid in Fuil O Outstanding Balance Due:
MNt'r-� to Ibo/if.
I
i
SECTIO45: CONSTRUCT ION SERVICES
5.1 Construction Supc ISoF'Liccilse(COL) y t3
d r :'I Q Ltcensc umber Expiration Dare
i �
Nainc ofCSL Holder R" • '%F ; List CSL Type(see below) LA
�rLc W.Palm M
. Description ... .No.and Street Hl(OIl tfee( Unrestricted Buildin a "to35,000w. It.Salem NIA 01970 Restricted 1&2 FumiL DwellinCitylTown.State,ZIP Musa
Roofin Covenn
Nindow a d SidinSolid Fuel Burning Appliances
✓/ 1 Insulation
Tele hone
Email address D Demolttion
5.2 Registered Home Improvement Contractor(HIC) J�2 J q 3 J Z /Z,
FlIC Registration Number Expiration Date
HIC Campany Nam IC gi N
Email address
No.mid Street
city(Town State ZiP Tel hone
SECTION 6;WORKERS'COMPENSATION INSURANCE"AFFIDAVIF(M:G.Lc;1527 §25C(6) .
Workers Compensation insurance affidavit must c completed and submitted with this application. Failure to provide
this affidavit will_resuit in the denial of the lsluance a building permit
Signed Affidavit Attached? Yes.......... No...........O
SECTION 7a:OWNER.►UTHO/tITr1Tt0N TO BE.COMPLETED.W HEN',-- "
OWNER'S AGENT OR CONTt AC1 OR APPLIES FOR,BUILDING,PEMIIT'
1,as Owner of the subject property,hereby authorize
hs.,
n all matters relative to work authorized by this building permit application.
t9 act on my behalf,i f
Date
Print Owners Name(Electronic;Signature)
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is ue and accurate to the best of my knowledge and understanding.
C Iz z
Date
Pdnt Owner's or A ithonzcd Agent s Nami.( ectroinc Signature)
NOTES:
I. An Owner who obtains a building permit to do his
own work,ar an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program);will nut have access to the arbitration
program or guaranty Fund under M.G.L.c. 142A.Frei tmpoimni mforma l no on the H(C Progretn can be ound3[—
www Mass cov'ocir Information on the Construction Supervisor License can be found at wwtv.nrass oovldns
2. When substantial work is planned,provide the information ncludinglgtarage, finished basement/attics,decks or porch)
'total floor area(sq. ft.) Habitable room count
Gross living area(sq. ft.) Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches
'type of heating system Enclosed" Open
Type of cooling system
J. "Total Project Square Footage"may be substituted For"Total Project Cost"