54 FORRESTER ST - BUILDING INSPECTION (2) iie CommonwLia t-h"0'oo:t-" i�
1 r - ssac Usetts
Department of Public Safety
J, S1.1tv Building Code(781)C'MR)
01 Aioii 'Building other than aiilor a''I'Muilding'.1'amitAp 'Ic Illy,
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION
1: COCA FION(!'lease indicate Block Nand Lot#fur locations for which a street address is not available)
No.and Street cilv Town Zip Code Name of Building(it applicable)
SECHON 2*PROPOSED WORK
r FklilitlomMA State C',de ust'd
It E It New Construction heck here 0 or clieck.ill that apply in the two rows below
F\i.sting Building 13 Repair 0 Alteration Dir I Addition 0 Demolition 0 (Please till ouland submit Appendix 1)
k ",
C11,11 13 Other 13 Specify:—_
Arc building plans and/or('011NIf LICH011 Lit'Clollclits being supplied-is part of this permit application? YLs C3 No W
---
Isan Independent Structural Engineering Peer Review required? Yes C3 No a
Brief Descripth of Proposed Work
ex I 4-1b,CA =Im paid VW to
M(MSECTION 3:COMPLETE THIS ECTION IF EXISTING BUILDING UNDERGOING RENOVA_rIONADDi'rlON,oil
CHANGE IN USE OR OCCUPANCY
Chuck hert!if an Existing Building Investigation And Evaluation is enclosed (See,7,90 CILIR.W) a
Existing Use Group(s): I — I Proposed Use
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fftx)r(sti.ft.)
Total Area(sl.ft.)and Total tivight(ft.)
— SEcrION 5.,USE GROUP(Check as aeplicable)
\-213 Nightclub C3 A-3 E3 A4 0 A-3 C3 1 0: Business 0Educational 0
F20 If: Hi Flazard 11-10 H-2 0 If-3 0 11-40 11-5 0C3
1; institutional I-1 0 1-2 C3 1-3 El 9.4 C3 M: Mercantile 0 R: Residential R-10 R-2 C3 R-3 0 R-4 E03
S: StorageI Special Use 0.111d ,lease describe below:
sEcrlON 6:CONSTRucrlON I-YPE(Check
IA C3 IB 0 IL% r3 F 0 1 VA 0 \,if C3
si:criON7.,SI'I'EINI:014,\fArION(rcft!rto 780CSIR 111.0 for details an each item)
WaterSupply: Flood Zone information: Sewage Disposal: 'french Permit. Dcbri5 tenitival.
Public El clit"),it"Illmde Flood zoll'.0 111% A trench will[I'll be Li'vil"'d Pivos'll Site 0
1 0
LO S B*It 0 1[fit 13 1 C3
S '4 if,'g
I C NO, 7.SITE 1._q I OR.\ \rl(),,
S
Water
-,pply."'&," C3 .....I"I'C3
Private 0 or indt-Illitv required Oor Arent Or spet ifv
I I permit isell,losed 0
'if
d v�y
I(Alroad right-of-way: 11-1/irds to Air Navigation:
�Xal 'l 1,'It",J"r
A4v 0 Is�Iro,lure%,ithiii,itri...rt.111111" It harej.' is
li'vir wv wiv tomplvred.'
or coii,erit to lltitld,-ri,I......IC3 `tvs 0 ,-r No C1 "s El Xo 0
Sl:( UVANCY
'I.Iwool C"'It. L w Urviijqa) kpvol 6,tisirmijot 0,,ly.1tit LraJ per I loor
bijildijl)�
I r
tilit._HON ): ilitt)l'1'ltl'YOWNI:lt AUl'll()ItIZ,VI IUN__-
.Naute end Address of Property Ow❑er
L, tvdc, _AJs„J ._z'4rv �-tP -.._S.r —
Name(Print)
No.and Street City/Town Zip
I'ruperlV Ownvr Clmlact Infonn,ttilm: r,ol[thF�ir �QOI•�
Title Telcplume No.(business) relephone No. (cell) e-mail address
If applicable, lh- ro,erty owner hereby authorize:
Name Street Address City/Town State Yip .
to,lit on the property owner's belmlf, in all matters reiativc h,work authorized by this building, uantiba ++Iication. +
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildin I is Icss than!i,01)(1 cu.ft.of enclosed s elce and or not under Construction Control then check here O:md-skip Section W.I
l(),I Re+istered Pr fessional Res onsible for Construction Control
-4AK ,S _�111�- 0 o J tZ�lc2PP�rrfm
Nam R Istr nt — �}�plhut Na A c-mail as d Registration Number —
Strut Address 11 City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cot tpany N.ua' - .
desq�►N
i e of Person�RA �punsible for Construction r f. icense No. and Type if Applicable
/Alk ]:(&1e#4it1P Al _85_
Street-Address - City/Town State Zip
Trio+hone No. business Telephone No. cell c-mail address
SECTION IL;IN'_a:!_tl1'i0-MI-1 N";y1It,\i.��_a n:.).�f'I..yl 111+.;t'1I M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents mustbe completed and
Submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application?. Yes O No 0
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item anal Materials) Total Construction Cost(from Item fi)
I. Uuildin+ S Building Permit Fir=Total Construction Cost x—(limert here
2. Electrical S appropriate municipal factor)-$ -
1. 1'lumbiny, - S
!. \Ica'hanii al Nu
(HVAQ S t: \liniment fee-.S--(anuait mu tic ipality)
S. \Icihanic.d (Other) S Enclose shark payable lu
(,. I'otal Cost S ra (anttacl munictc).md wrilechcck number here
SECTION 13:SIGNATURE OF BUILDING PERMIT AI'PL[CANT
Ity cnwrinp,nw "ante ,elow. I hereby attest under the pains.uld pcnaltics of perjury that all of the information contained in this
applic, ion is true an I, aerate h,the hest of olt' kno„IrdltV and understn,ding.
d_ 9�� �905"�Oa �
tMn in RyA� . ,l -- - S/
-- - -.- --_ _..._
I'L•s. cut.utd sign nano. - �._— _I"[Ilse � folcphone No. Date
�lnrt Address tty; ,ca h• t +
r
.\lunicipal Inspector fo fill out this smiun upon application approval: __
_. __ Name I+a a
r 1
CITY 0 SM-F- ,I, NWSACHUsETTS
s ULILOING DEPd WrMF_iT
120 WASHLNGTON STREET, Y°FLOOR
TEL (978) 745-9595
.��(973) 140.9844
.Q.\(OE.RLEY MUSCOLL ,
T
�rLiYO:t HOSL►S ST.PIE.gAB
DlaEcraa OF PL9LIC PROPERTY/suriDNG CONNISSIONER
Workers' Cumpensation fnsurance AtT(davit: 0uildens/Contrac It)rVElectricfans/Plumbers
iinlslleant Informutlnn Pleam Print Legibly.
Namellusi/lbw`..a'O'p`rg'amralian lmlividual) 1 V s / 1L 1 R�
Address
CitylSratcyZip. I��rylhUnem: "( ?(F� —7 /0 S I00
Are you in umployer!Check the appropriate bon •r yp.of Project(required):
1.❑ 1 am a employer with..1_ 4, 0 I am a general contractor and 1 6. 0 Now,construction
dnlployees(Nil and/or part-time).* have hired the sub-contractors ,.�,,�
2.0 1 am a solo proprietor or partner- listed on the attached sh"L: �• J31emodeling
ship and have no employees These subcontractors have V. 0 Demolition
working fiar me in any capacity. workers'comp.insurance. 9. 0 Building addition
(No worker:comp.insurance 5. [] We are a corporation and its
required.) officers have dxerdiccl their 10.[]Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions
myself.[Na workers'comp, c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.l t employees.(No workers' U.❑Other
Gump.insurance required.)
•.cry appllum Thar chaeka bon rl must also rill out IN"Baca balow ahowina Ihair asknt a 'compsnaatun puliuy in0arrnmion.
'I(r-vuwmw who,Ubmil This s ffeAvit indieaing they am doing ail ware and III=him"'side wuncras Mimi mhmil a new 31lId4rlt;ndIaing such,
<'.rmmcton Ihol chwk his boa must mach d an aJlkuund ahaet showing the nwna of Ihervb<unlneture anJ(halt workers,wmp.policy rote noolom
/urn an entplayer that br providlnB)vorkers'a umpensailun Luarance for.MY emplayeess Below is Nu poNgr and Job site
informatlon. 1,/I , 1/►/1�
Insurance Cootpiny Name: �r,�In r� 1e"J-(J�VW 1 /�
Policy U or Self-ins.. La�ic((N: VV C lJ, 'i N 5 � 57 1p `Expiration Date: O ('6 20
Job Site Address: EA ron�is �� ST Cily/Slute/Zip:. S-FP At a M g�j r
.sitacb a copy of the workers'compcnsatloa policy declaration page(showing the policy number and expiration date).
Ktiluru to wcuru cuveraga as required undar Scction 25A of JtGL c. 152 can lead to the imposition of criminal penalties of a
tine III)to 51,500.U0 undlur one-year imprimtnmm as well as civil penalties in the form of a STOP WORK ORDER and d tide
of uI)m UAW a day against list violator. Ile advi.aed that a copy of thir Maiement may Ix furwardcd to ilia OI'rice of
fit vcsti gal ions orllle 01A fur insurance coveagc vcrilicatiun.
/do lrereby veiliAy uadrr ll a ids Oita penalties of peryary drat the la/urnradoar provided above i. true dad correct
lyar
aLj Stoe
Ul/icial we only. 111 ,at 1wire ilt thin area, td be completed by city at rown.r//iviuf
Gry ar Town:
I.,oia;.\uUlarily (circle nne)t .. ...._-
1. hoard of Ileallh 2. Iluilding Depaf noeal .1. Cilyi Iblvn Clerk J, h:1cerric.11 Lllpectur i. Illumhinv ludpeetor
4. Other
11n 11.1�t 1'efvnn phnnl`.r:
CITY OF 5.11zm, 4tickss.WHUSETTS
JLLLOLNG DEP.IAT)Ip,`T
170 1A.IiHLVGTON STXM, J'O FZ.00It
T'�L. k978) 145.9599
!U Fkx(973) 140.9&w
MAYOX Moss ST.?Yids
DIASGTOR OP Pt OLtC PROPf!ltTY/3"nLN'G CO-%OIISSIO.�EX
Construction Debris Disp084l Affidavit
(required for all demolition and renovation work)
In accardance with the sixth edition of the State Building Code, 78o CbiR section 111.J
Debris, and the provisions of,%t(;L a 40, S 34;
Building Permit 11 is issued with the condition that the debris resulting from
This work shell be disposed of in a properly licensed waste disposal racility as defined by NICE e
111. 3 IJOA.
The debris will be transported by:
�Pl�l /dum ()
(name of hauler)
The dreebrij wi If be disposed of in
I,dara,ar n„I„y)
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Jun211209:25a 9785215729 p.1
Lwm u1�01�1 LY IN�nteoar>tce
OWilyWork CSL#W4
Affmd"F`4ms HICaHOW
Fully Insured
Rwv d bet Full SWVIW
Additions PWPWv id erd
An Rgan Linda Nolan
R%mbs of a9 Wnds (978) 521-57" RE: Fon+estw St
Vr8•=WftW•Mbbro••meu Salem, Ma.
June 20, 2012
Work proposed:
• Renxw existing porch
• Remove any unnecessary shrubs and soil
• Jack hammy underlying cement apron and remove as necessary
• Install 6 new 10•x4V cementfoodags
• Build in now dedk and stairs as per approved drawings(accompanying documents)to
the following specifications
Pressekne treated lumber for rough framing with appropriate hangers and flashing
Plastic Axek decking(brown)
Mastic 711mbertedr•Radiance bandralls(white)
Plastic Ialtice(white or green)
Plastic trim boards(white)
• Pour cement walkway appraL.4'd x 360W x 72"L
• Finish grade rest of dirt area as required
• Pull permits permits as required
• Remaveail debris
• Perform work In a profesdlonal and timely manner
Sl ock and labor.$12AW
Payments to be made In the following manner.One UM when contract is sigred.2a°third
when deck and pasts are installed. Final payment at completion of job and sign off by bldg.
inspector.Eetiaoted tam of completion Is 10 work days from when existing porches are
re moved,wed permitting.
UID12
Jim Ryan
4 New Hampshire Ave.
Bradford,Ma 01835
1-978-790-5100
F-1978-521-Mg
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