15 FOREST AVE - BUILDING INSPECTION I� The Commonwealth of Massachusetts
Board 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 Number: 1,11ate Applied•
Building Official(Print Name) SignaturV Date
SECTION 1:SITE INFORM
1.1 Pro��perrtt�ddreas: � 1.2 Assessors Map&Parcel Numbers
1.Is Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(ft)
1.5 Building Setbacks(4)
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 ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1, Owner'of Record:
xlxr�'t I gg,& ,v9A� M6q 60-20
Name(Print A City,State,ZIP
Ivy ST /T�L �2� �� e A b�4CCrSU �kiavl
No.and Street Telephone ail Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : CAA
�net�t size a7'x�^
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:
2.Electrical $ ❑-Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x`
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees:$
6.Total PtojeCt Cost:
Check No. Check Amount: Cash Amount:
$ ` (a.4 y p ❑Paid in Full ❑Outstanding Balance Due:
Ynac� ob ��htPrjul�
SECTION 5: CONSTRUCTION SERVICES
5.11 Construction Supervisor License(CSL) � 477'20
1.\C40oz) A_ License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
t�»z Ea2ms Roams
No.and Street Type Description
��S�� lm� ��2� U Unrestricted(Buildingsu to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
CKP-20'. Nol S26CwDsw) (yl ( m a)i I Insulation
Tele hone Email addrvZs�— D Demolition
5.2 Registered Home Improvement Contractor(HIC)
S �Sti' �rtoo Gc .SCr 1 oq�aS S �1• ZofZ
k-' ) HIC Registration Number Expiration Date
C Company,N,aK HI N e
N an Street Email address
.
� 6h O\Cj7q �7��z� -C1�Q1
City/Town,State,ZIP 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 IssuarF 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&A�Ro S%-�16 r<.S
to act on my behalf,in all matters relative to work authorized by this building permit application.
'S(iz�LJC- W'pqg_zg.zat
Print Owner's Name(Electronic Sign 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
co ed in this applica'on is tine and accurate to the best of my knowledge and understanding.
PA Owner's or AuihdYzed 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.gov/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"
CITY OF S.U.F:N4 LXSSACHUSETTS
BUHMLNG DEPART.%MNT
• 120 WAS LNGTON STREET,3'a FLOOR
TEL (978)745-9595
FAX(978)740-98"
KlxiBERIEY DRISCOLL
THOAtAS ST.PtERRe
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �j Please Print Legibly
Name tBusiiwss organizatioNlndividual) �Ppt-,( S,If—If :1b,0A b{ifs\I�)7 (�CfJ a>St y WCi/
Address: k4lL- $ t )pm wQil.
City/State/zip:E&L MA- 6kokZ3 Phone#: 1,12P-?Ir&-9.
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
p iployees(full and/or part-tithe).' have hired the sub-contractors
2. 1 am a sole pmprictor or partner- listed on the attached sheet t 7. ❑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 10.❑Electrical repays or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself. No workers'comp. c. 152, 1(4),and we have no
y' [ P � 12.❑Roof repass
insurance required.)t employees. [No workers' 13 ❑Other
comp.insurance required.)
•Any appliuua that ducks bus el most also fill out the section below showing their workers'compensation policy infuaoation.
'I btmeownaa who submit this affidavit indicating they ate doins all work and then hire outside contractors must submit anew amdavit indicating such
:Contracto.What check this box most auached an additiorul short showing the mascot the sutlNrnnactar,and their workers'tromp.policy infarmntion.
I tint an employer that is providing workers'compensation insurance for my employee. Below Is the polley and Job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 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).
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 imprisonment,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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do here •erd er he inns set xa/ties of periary that the information provided above is true and correct.
Sim t e' ty Dole,
P n #: q &? _'?(vQ — 11i bO)
OJJ/ciai use only. Do not write in this area,to be completed by city or town aJfciat
City or Town: i Permit/I.1cense# __
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityifown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other .
Contact Person• Phone#•
,_ ° CITY OF S.��I, UxSSACHUSETTS
• BL'ILDL\G DEP ART\MNT
• N 130 WAISHNGTON STREET, 3'�FLOOR
'�'=aj TEL. (978) 745-9595
FAx(978) 740-9846
KIN
iBERLEY DRISCOLL
MAYOR THmu.c ST.P[ERRE
DIRECTOR OF PUBLIC PROPERTY/BuILDIING 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 I50A.
The debris wild be transported by:
-N CN'AL'Tl 1r��L—J' pz c l t'zu
(name of hauler)
The debris will be disposed of in
(name of facility)
se5s'i &rA7 �6�L6tV�
(address of facility)
VAsignatureaofpc—rmitaapplica=nt
�U d51e
dcbrisutl�dce