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11 FAIRFIELD ST - BUILDING JACKET 9 The Commonwealth of Massachusetts / I W :Building Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM lU'J Revised Mar 2011 Permit Application To Construct,Repair,Renovate Or Demol' a One-or Two-Family Dwelling _ This Section For Official Use Only _ - BuildingPermitNumber: Date Applied: t�'.LrGU�r1LL� �y'C'Q-ZYY-�'t-•�,S�G� _ uiding Official(Pant Name) -- Sig tur Date u SECTION 1: SITE INFORMATION 1.1 Proopperty Address: / 1.2 Assessors Map&Parcel Numbers 1.la 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❑ Private❑ Zone: Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSILP' 2.1 Owner'of Record: Nam(i�I JRG�CGcfln �r�^� /��If� �� Y�C❑ rint� City,State,ZIP it rc,ew` e-f.P S-E -*1�yo bYlo No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply),,,., New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work : / O v� 'SECTION 4: ESTIMATEDCONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials - I.,Building $ 1. Building Permit Fee: $ _ - • � Indicate how fee is determined: 2. Flechical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier `M x 3. Plumbing ) $ 2 Other Fees: $ ( L 4.Mechanical HVAC $ List: : 5. Mechanical (Fire $ Suppression) Total All Fees:$ . / Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ( OQ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supeerrviso License(CSL) 10 /0 Lib _3 Z License Number Expiration Date Name of CSL Holder 9 /jam p� I h List CSL Type(see below) No.and Street Type Description "n r l v�JG h I^ // f U up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Mason ry 036J"1 RC Roofing Covering /� WS Window and Siding .7 �_/% a(,+,� SF Solid Fuel Burning Appliances / aJ/ I Insulation Tele hone Email address D Demolition 5.2 Registered Home Im/,g)rovement Contractor(HIC) r� <� _/7`/ Zone t/C % /G✓i HIC Registration Number Expiration Date Hl�Co any Name or HIC Registrant Name C J@�.6 IPG�f1 / h/ N�n¢�eet pdh / 7Z�/^ n� Emai]address Ci //((Town,State,✓ZIP Telephone? d' SECTION 6:WORKERS',COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c:I52:§ 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 to act on my behalf,in all matters relative work auth ed by this building permit application. Print Owner's Name(Electronic Signathf6YT Date SECTION 7b:OWNERPIORAUTHORIZED AGENT DECLARATION '_- e By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information cents' d in this application is true and accurate to the best of my knowledge and understanding. eY /,� -< l - 2-?- / 2 Print Owners or Authorized Agent's Name(Electronic Signature) Date 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. I42A.Other important information on the HIC Program can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.my/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" 3 71 The Commonwealth of Massachusetts W OF Board of Building Regulations and Standards CITY MMassachusetts State Building Code,780 CMR SALEMRevised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a 1U One-or Two-Family Dwelling I This Section For Official Use Only Building Permit Number: jj Date Applie /lie vCtaz�.11..�C� Building Official(Print Name) rgna a Date SECTION 1• ITE INF ATION 1.1 Property Address:,1 .2 essors Map&Parcel Numbers 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 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: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system El SECTION 2: PROPERTY OWNERSHIP' 2.1PwOnLecot,:e tsv� Svc I�Nr, vv�c. o Name(Print) City,State,ZIP tl C,4 N,2 �l-QAJ. 41 f( No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Pri Alteration(s) ❑ Addition ❑ Demolition - - ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': w�o J.,� Gv�d� It ✓L ra. -- -- - SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: $ Total Project Cost: $ Check No. Check Amount: Cash Amount: 6. do fj ❑Paid in Full El Outstanding Balance Due: `� �' � 0ne SECTION 5: CONSTRUCTION SERVICES 5.1/'Construction Supervisor License(CSL) —1,.r U ° L C CS - 1 0Z 3So PO 1 r'f � �� License Number Expiration Date Name-a Ider �7 of i I List CSL Type(see below) Type Description No.and Street Description �n`n i1 J�n �� © V� k C) U Unrestricted(Buildings2 Fm u el ing cu.ft.) Y'1y 1 A R Restricted l&2 Family Dwelling City/Town,State,ZIP M Maxonry RC Roofing Covering CIWI 1. WS Window and Siding '��'��Z (/�� pp CAKA1 SF Solid Fuel Burning Appliances oll,If 7 I IInsulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ( (O y g ( 0 (0 ( 2013 ( 'Y)'t.." nka=-!t C-�� 'k HIC Registration Number E piration Date HIC^C�om any e or HIC Wgistrant Name -/ 1 _ ,t ` 3 � %a Cal ✓\C V-G � r It ��HS'l�Ll3C�W\�1-C-D No.and St et Email address C /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 Issuance of the building permit. Signed Affidavit Attached? Yes .......... It- - 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 C IC.1'K ( 17riSf Jd)UM to act on my behalf,in all matters relative to work authorized by this building permit application. -a, I J ockson � 6 2010 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. 4,4 o=�-4 L-CiAwp I P Owner' Authori ed Agent's Name(Electronic Signature) Date __ -- — - -- 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. oe v/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" • r, / I The Cummonwcallh of Massachusetts Town of Board of Building Regulations and Standards lommo1w Massachusetts State Building Cole, 780 CMR, T"edition , Building Dept Building Permit Application To Construct. Repair, Renovate Or Demolish a alum One-or Tiro-Firm iA Dsvel ng is,Sccnon For unic)i1i Use Only Building Permit Number Dat Applied: Z d Signature: Building Commission Inspect o tINV Dale Tr SE TI N :SITE INFORMATION 1.1 P apes AddVr, S 1.2 Assessors Map 6 Parcel Numbers. hlt_ I.1 a Is this an accepted street''yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use La Area(sq n) Frontage(11) 1.3 Building Setbacks(It) Front Yard Side Yards Rev Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c. a0.154) 1.7 Flood Zone Information: 1.2 Sewage Disposal System: Zone: _ Outside Flood Zone? Munici al O On site dis sal system O Public O Private O Cheek if esO P po Y SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of ReeoKd: T7S..W \flr.bC6eJ Name(Print) Address for Service; Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek sit that apply) New Construction O Existing Building O Owner-Occupied Repairs(s) O Alteration(s) O Addition O Demolition O Accessory Bldg. O 1 Number of Units_ Other O Specify! Brief Description of Propgsed_�rk°: �9 SECTION♦: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building f oz> 1 1. Building Permit Fee: li Indicate how fee is determined: O Standard City/Town Application Fee 2 Electrical f O Total Project Cost'(Item 6)x multiplier x ) Plumbing f 1. Other Fees: f d. Mechanical (HVAC) S List: 5 Mechanical (fire f Total All Fees: f Su remon Check No. _Check Amount: Cash Amount:_ 6 Total Project Cost: f � O Paid in Full ❑Outstanding Balance Due t SECTION S: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) O '((�� Li.•rise Number Es irauo Date 14.4m I'(' L Hplder �� List CSL Type fscc below) e} Ts Description AJJW5sj U Unrestricted u to 35.000 Cu. Ft. —\L :1'V��` '� �� R Restricted Ih2 Family Dwelhn Si tare fl .N %fasonry Only RC Residential Rooting Covering TelephoneP Z WS I Residential Window and Siding SF I Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 ISIarered Hot ImprovemmtContractor(HIC) 1 .4N�y M �ta HIC Co y arse or HIC Registrw N,,��nn�e Re)pstratron Number B�'"U17.1 S vHo, o ()_ A te` ® ExpilraiussfDate Signature Te ephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.J 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. Signnl Affidavit Altached? Yes.......... No........... O 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Si nature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 1 QWJ,e `�L i; as Owner or Authorized Agent hereby declare that the statemeAts and information on the foregoing application arc true and accurate,to the best of my knowledge and behalf. fX'rt� C i Print Na ` nc* Signature of Own or Authorized Agellf Date Fliving under the ams and penalties of r u NOTES: Owner who obtains a building permit to do his/her own work.or an owner who hires an unregistered contractor ot registered in the Home Improvement Contractor(HIC)Program). will g&have access to the arbitration ogram or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and nstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R5. respectively. hen substantial work is planned,provide the information below: oors area(Sq. Ft.) (including garage• finished basement/a0ics,decks or porch) ving area(Sq. Ft.) Habitable room count r of fireplaces Number of bedrooms of bathrooms Number of halfbaihs heating system Number of decks/porches cooling system Enclosed Open tal Project Square Footage" may he substituted for-'Total Protect Cost" 4 The Commonwealth of Massachusetts , Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR 7' MUNICIPALITY edition USE Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised January One- or Two-Family Dwelling I, 2008 Thiy9*iJp.For Official Use Only Building Permit Number: Date Applied: Signature: Building Commis 'oner/Inspector o'f ' mgs Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 11 Fairfield Street 34 0034 1.1a Is this an accepted street?Yes X no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: R-3 Two Family 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 Owner'of Record: " Philip Jackson 11 Fairfield Street Name(Print) Address for Service: Attached Contract/Authorization Letter 978-317-1100 ` Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify: Brief Description of Proposed Work : Install(2)8'x8' Replacement Garage Doors. Non-Structural. SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $5,273- 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $0 3 ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $0 2. Other Fees: $ 4.Mechanical (HVAC) $0 List: 5.Mechanical (Fire $0 Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $5,273- 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) CS 97519 08/31/2010 Lubos Svec—Sears Authorized Agent LicenseNumber Expiration Date Name of CSL-Holder 827 Thompson Rd. / Thompson,CT 06277 List CSL Type(see below) U . Address Type � Description U - Unrestricted(up to 35,000 Cu.Ft. R. Restricted 1&2 FamilyDwelling Signature M. MasonryOnly 860-753-0452 RC Residential Roofing Covering Telephone - WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) Sears Home Improvement Products Incorporated 148607 HIC Company Name or HIC Registrant Name Registration Number r. 1 24 lorida C ntral Parkway/Longwood, FL 32750 Add s _ $Z3ar-5 10/11/2009 407-551-5402 Expiration Date Signs ure 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 ..........0 No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, Philip Jackson as Owner of the subject property hereby authorize Sears Home Improvement—Lubos Svec—Auth.Agent to act on my behalf, in all matters relative to work authorized by this building permit application. Attached Contract/Authorization Letter. �Gt 4i Pi s� 3 , ZOr>g_ Signature of Owner Date' - SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION I, Lubos Svec—Sears Home Improvement 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. / Home: 860-792-8106 Lubo Svec—Sears Home provement-�AuthorizedAgent / Cell: 860-753-0452 Print N Si ture Sf13"wner orc&t on Date,/ (Signed under the pains and penalties of e 'u + - 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementlattics, 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"