178 FEDERAL ST - BUILDING INSPECTION The Commonwealth of Massachusetts
�I s Board of Building Regulations and Sta1tEtiO"AL SERV E CrrY of
Massachusetts State Building Code, 780 CMR SALEM
c>^° '�t��1I n'N ��S rvecJ Mar 2011
Building Permit Application To Construct, Repair, RenolAw t�l"t7e'$olish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
V�R1S(kt-'E20N1 hA /�� " Y fl9
Building Officiat(Print Name) Signature ate
SECTION 1:SITE INFORMATION
L1 Property Address: (�L 1.2 Assessors Map&c Parcel Numbers
-/ ��— _
L I a Is this an accepted street?yes no Map Number Parcel Number
1.3 "Loving Information: 1.4 Property Dimensions:
Inning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rcar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.6.L.c.,10,§54) 1.7 Flood 'Lone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record-
—ov
No. and Street 7h�-
telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) < Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specity: _
Grief Description of Proposed work':
r �h — — c� -fD2tc� — n)o ou7 stogy
SECTION d: Es VNIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical S ❑Standard Cityfrown Application Pee
❑Total Project Cost'(Item 6)x multiplier x_
3. Plumbing .5 2. Other Fees: $
4. Mechanical (1IVAC) $ List:
5. Mechanical (Fire Sit) ression) $ Total All Fees: $_
Check No. Check Amount:_ Cash r\mount:__
6. Total Project Cost $ lee Od_— ❑ Paid in Full Cl Outstanding Balance Due:
-ro CAD N TT-Vae ,l? (C
SECTION 5: CONSTRUCTION SERVICES ,
5.1 Construction Supervisor;:License CSL)
hZw EY14 ✓t- r S License Number Fxpn Lion ate
Mum of CSL Holil,rA p
// r'''k �� List CSI,flype(see below) u
I 13'a Of f' ee Type Lion T Descri
No.and Street P
U Unrestricted(Buildings u to 35,000 cu. 11.).
R Restricted M2 Family Dwelling
'Uiityffown,State,ZIP
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Q 7/ — -S / .5 ,9 +'>7R/ �� C 0/�✓� I Insulation
Telephone 'mail address D Demolition
5.2 Registered Home Improvement Contractor(IIIC) 15
HIC Registration Number
HIC'Company Name or HIC Registrant Name Expiration Date
No,and Strcet
Email—address
City/Town, State,ZIP Tel, hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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
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.
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.
Print Owner's or Authorized gent's Name(Elec(ronic Signature) Kate
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(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.uiass.gov/oca Information on the Construction Supervisor License can be found at www.ntass.sov/dps
2. When substantial work is planned,provide the information below:
Total Floor area(sq. fl.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room coma
Number of fireplaces _ Number of bedrooms
Number of bathrooms_ Number ofhalf/baths
Type of heating system Number ofdecks/porches _
Type of cooling system_____— Enclosed Open
3. `Total Project Square Footage"may be substituted for"Total Project Cost'
CITY OF S:\LE�I, AASSACHUSETTS
BUILDING DEPART\lG\T
120 WASHINGTON STREET, 3an FLOOR
TEL (978) 745-9595
Rux(978) 7.10-9846
KI\i$ERLEY DRISCOLL
,�L�YOR THoms ST.PIFRRH
DIRECTOR OF PUBLIC PROPERTY/BUILDRG CONCAISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeQibluy
Naine(Rusin/css0(g,miratinn;ln,lividual): `� F, n B C
Address:_/ �V
City/State/Zip: Ag" ✓e+-1 //////T Phone Jt:
Are you on employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4, ❑ I am a general contractor and 1 6. ❑New cunsuuction
employees(full and/or pan-time).• have hired the sub-contractors
2�1 tun a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
.hip and have no employees These sub-contractors have 8. (] Demolition
working for me in any capacity, workers'camp.insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑"We are a corporation mid its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers'sump. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurancerequired.J I employees. (No workers' (},❑ Other
cutup. insurance required.)
•Any appkum door checks box BI mull also fill uul the scstiun bdowshowing their worker'compensation policy inrllesatiun.
'1lomunwwra who submit this atntLnvis indicating they ass doing all work and then hire uulside contrnor most submit a new afndavit indicating such.
$'nmracturs ihul ch vk this bus must mtachud an addiliurad ehut showing he natne of tho mbsenrnetun and their wvrken'comp.policy infuriation.
I am an employer that Is providing workers'compensation insurance for my employees. Belov 1s the policy rand job rile
imformatinn.
Insurance Company Name: __..---
Policy 4 or Self-ills. Lic, b: 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).
F'ailuru to secure coverage as required under Section 23A ot'MOL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisomncnt,as well as civil penalties in the t'orm of a STOP WORK ORDER and a line
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 nl'the DIA for insurancd coverage verification.
I do hereby certify rider the ins and pentrltie of perjury tbat the hefonnation provided ubuve is true and c'orretrL
llrn' I fC' Dnfd:
Official use wily. Do nor write in this urea, to be completed by city ur town njjlclatt
Ciry or l'mwn: __ Permit/Liccnsc q
Issuing Authority(circle one): _ --
I. Board of Ilealth 2. Building.Departnleot .l.Cityawsi,Clerk 4. Electrical inspector S. Plumbing Inspector
6. Other
Cunldct Iscrson:_____ .. _...___ Phone,Y:
CITY OF SOU E1,t, ftiL1SS:ICFIUSETTS
BLILOtNG DEPARTMENT
Z�t 120 WASNNGTON STREET, 3w FLOOR
TEL (973) 1{5-9595
KIMBERL EY DRISCOLL FAX(973) 740-9345
X Li YO a 7 HOAAS ST.PIE UM
DMECTOa OFPUOUC PROPERTy/HCILDLNC;CO\L\nSSIONER
Construction Debris Disposal At'tldavlt
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 Q fR
Debris, and die provisions of NiGL c 40, S 54; section l l I.5
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed ot'in a properly licensed waste disposal facility as defined by d(GL c
tl1, S
The<Ichris will be transported by:
k �. s
(nJntc at haulc
The dchris will be disposed ot'in
(nanlco(fjeltitY)
PJ Jres.c of'rit�ility)
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