20 FEDERAL ST - BUILDING INSPECTION (12) 41 (oIR $1 CFO 50'b
The Commonwealth of Massachusetts
UlfBoard of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
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 umber: D ppf
wilding ffictal(Print ame) Si re Dat
SECTION 1: SITE I&FORMATION
1.1 Property ddre 1.2 Assessors 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.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 1" Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofRe or a01 / Q`5?�Q
Name(Print) rty,State,ZIP
gar _ b a f`
No.and Street Telephone Erdail Addre
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief D scription of Proposed Work': e O Q
u/ O
r
10,
SECTION 4:-ICSTIMATE' 6 CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 000,E 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 $ m0. 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
D Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
�� db C� �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction
nstruction Supervisor License(CSL) Ui�
7Z,wll, .,Ij�G � License Number Expiration Date
Name of CSL Holder
7 ? List CSL Type(see below)
No.anti Street /�(� Type Description
/YID`J ,a1w� /j7 Q�.�y U Unrestricted2 Family
(Buildings u el ing cu.ft.
CiittyyrroGwn,n,State,ZIP' R M Restricted l&2 Fami1 Dwelling
M Mason
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Tele hone Email ddress D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC 3� i3
Registration Number Expiration Date
HIC Company N e or H Registrant Name
d's s
No.an S t
4V/ , -1W mail address
City/Town,State,ZIP
Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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 authorizeOre .J f Z
to act on my behalf,in all matters relative to work authorized by this building permit application.
44W All,
r nit Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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. 7 G�
a10�/
Print Owner's 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. 142A.Other important information on the HIC Program can be found at
www.mass. oe v/oca Information on the Construction Supervisor License can be found at www.mass.gov/des
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemenVattics,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"
CITY OF S�UX.N1, NLA SSACHLSETTS
• BUMDLNG DEPARM NT
\ dam 120 WASHINGTON STREET,Sao FLOOR
TEL (978) 745-9595
FAX(978) 7404846
KI\tBERLEY DRISCOLL
MAYOR THoMAs ST.Pwzn
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG COSMSSIONER
Workers' Compensation Insurance Afledavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Maine(Busim-s&Organization/Individumal)a:
Address:
City/State/Zip: Zyl_ / gga�Phone #:_12���J'' 'I 6J`
Are you an employer?Cheek the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
p sub-contractors
(full and/or part-time).* have hired the sucontractors t
2. 1 am a sole proprietor or partner- listed on the attached sheet.: 7. Iy0 Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9, ❑ Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.ff Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.VPlumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no I2.❑ Roof repairs
insurance required.]t employees. [No workers' 13 ❑Other
comp. insurance required.]
•Any applicant that checks box it I most also fill out the section below slowing their worker'compensation policy information.
I hxncownrn who submit this affidavit indicating they are doing all work and then him outside contractor must submit a new affidavit indicting such
Contractor that cheek this brat must attached an additional shoes showing the name of the sub.contraetots and their worker'comp,policy inttmmatimt.
I am an employer that Is providing workers'compensation Insurance for my employees. Below Is the pollay and Job site
information.
Insurance Company Name: ry�1 ! �fGjl7/Q///i� p, �i �/
Policy It or Self-ins. Lic.q: O tfV0/reJ per! n Expiration Date: 0 �O -i ZZ7114
Job Site Address: 7,0/e�� City/State/zip: ��///�� V
a --
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration state).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonmen%as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
!do hereby cerNjVitder lite painsd pens ties ojperJury that the information provided above is true and correct
Sit,, at ire: 2/ oz z � Date'
Phone : ,�o�'/d
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License g
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: __. Phone M
J 1 1
1
CITY OF Siuzm, XWSACHUSEM
• Bt:u.DLNG DEPARTMENT
120 W.iSHLNGTON STREET,3" FLOOR
TEL. (978) 745-9595
FAx(978) 740-9W
KIJBERLEY DRISCOLL
MAYOR THonuc ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BCIIAING CO\LMSSIONER
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 debris will be disposed of in
Z1 a�z�� 4/ X?9 _
(name of facility)
(address of facility)
signature of permit applicant
date
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