14 FORRESTER ST - BUILDING INSPECTION t The Commonwealth of Massachusetts RECEIVED
° Board of Building Regulations and Stat CTIONAL SER ICESCITY OF
Massachusetts State Building Code,780 CMR R SALEM
`
Building Permit Application To Construct,Repair,Renovip"k 1 listh 11. ��sed Mar 2011
One-or Two-Family Dwelling
.-t—� This Section For Official Use Only
Building Permit Number: to Applied:
` Building Official(Print Name) Signature Date
O 1
SECTION 1: SITE INFORMATION
1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
/
f`e 1 4Ti;1TVz S i
L l a 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(to
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.S Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Qwnerl of Record:
C2v c ��l_6:V41 hA d 19-7d
Name(Print) City,State,ZIP
1 -rz� 5T,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building JIB Owner-Occupied fit. Repairs(s) ❑ AI[eration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
N wlNv�w aw/) �,eEPrn�c c -
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1 oc-0 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 000 ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ (JCS 2. Other Fees: $ \
4.Mechanical (HVAC) $ List: (X7
5.Mechanical (Fire
Su ression) $ Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3 ❑Paid in Full ❑Outstanding Balance Due:
�r 3tsl ► s
SECTION 5: CONSTRUCTION SERVICES
q 5.1 Construction Supervisor License(CSL) gy
---L J•-�7q•Zl_ License Number 1 E pi tion Date
Name of CSL Holder I 1
List CSL Type(see below) t/
I C, ncpc L4 67-
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
City/Town,Slate,ZIP R Restricted I&2 FamilyDwelling
M Maso
RC Roofing Covering
WS Window and Siding
�s7�l4 SF Solid Fuel Burning Appliances
Telephone
" to // "GLB C'Clf+'/CpSJ,N I Insulation
el hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ,a t 96
HIC Registration Number Expi tion Date
HIC Company&ate or HIC Registrant Name
Vb
o.and Street tKza�—�Q� Ct�GI�-�ji
N .
Email address
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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........31 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 EZ-7 (jhx^— !�
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) r (/ v Date
SECTION 7b:OWNERS 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.
Ft-cm•ibyt 1-�AZ-L I
Print Owner's or Authorized Agent's Name(Electronic Signature) Pate
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.aov/oc Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
I
CITY OF Si-1I..Em. NLkSSACHUSETI'S
BuILDDtG DEPAR-MENT
\ td� 130 WASHIINGTON STREET, 3�FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
K1\tBEBL.EY DRISCOLL
MAYOR THobw ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUT1.13 VG COSL\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 defincd by MGL c
111, S 150A.
The debris will be transported by:
1��2tats ID6 CHn nV
(name of hauler)
The debris will be disposed of in
1L S1/106 C�'Je"4,/
(name of facility)
�i y2r�rPS U� kd Z-6"
(address of facility)
signature of permit applicant
date
dcbriwlLd(w
CITY OF SM E:N i LXSSACHLSETTS
' BI:II.DLNG DEPART\mNT
• \\ �� 120 WASHINGTON STREET,3`a FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KI\IBERLEY DRISCOLL
:MAYOR T HOMA3 ST.PtEaRa
DIRECTOR OF PUBLIC PROPERTY/Bumni G COJL\DSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lee]bly
NalnC(BusinessOrganintionRndividual): F-2:' 14--Un I C_
Address: I L a- AVE
City/State/Zip: S A/-Em MA Phone#: of 79 SW6 I•I f /
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the subcontractors
2.4 1 am a sole proprietor or partner- listed on the attached sheet.: 7• g 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.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 L❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers' I3.❑Other
comp. insurance required.]
'Any applicant that chmits box#1 most also fill out the section below showing their workers compensation policy information.
t I inmeownms who submit this affidavit indicating they are doing all work and then hire outside contnctms must submit a new andavit indicating such.
lC:onumnors that check this box must anaehod an additional sheer showing the name of the sub-contractors and their worker'comp,policy information.
I am an employer that is providing workers'compensation insurance jar my employees. Below is the polley and job site
information.
Insurance Company Name:
Policy#car Sclf-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 bate).
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 S250.00 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 hereby certify underr/mire pulnsJuu penalries of perjury that the information provided above istrue and correct
SSi�•naitre: ��� /' Date! �
Phone X:
Official use only. Do not write in 1/14 area lobe completed by city or town offrriaL
City or Town: Permit/License#
Issuing Authority(circle one): r
1. Board of Health 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: