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16 FORT AVE - BUILDING INSPECTION (2) 4 75-. °o 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: Date p 'ed: 7Z wilding Official(Print Name) 1 Sipnatur DaLf SECTION 1:SITE INFORMATION 1.1 Property Ad ress: 1.2 Assessors Map&Parcel Numbers (pro Lla 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(tt) 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: Public❑ Private❑ Zone: _ Outside Flood Zone?Check ifyes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 O`�' er'of Re rd: I IMA ter l © P �ll�w1 r IQ . � ( ��2� N e(Pont) City,State,ZIP / "tlg qW s'gY7c��l Cavc/oap No.and Street 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 Accessory Bldg.6 Number of Units'Z Other ❑ Specify: Brief escription f Propo ed ork': a I to I � Q SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ b301. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee l J_ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ j 00r 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ 6.Total Project Cost: Check No. Check Amount: Cash Amount: $ `� ❑Paid in Full ❑Outstanding Balance Due: � � )_� f SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS l � 1 f l al I�Q,4 License Number J `Elx piration Date Name of CSL Holder 1 I __tt L 1�c 0.C1 STfeek pvVe-y\t,,�P- List CSL Type(see below) No.and Street T Description ryt J] O l�'�� Unrestricted(Buildings u to 35,000 cu.ft. City/1'own,State,ZIP 11 1 1 R Restricted 1&2 Famil Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 3 1s Kid42rOr�Pv�}SPr�,(eC (nnCas}.� I lnsulation Tele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Kt-; �-k Q , k 4 d �,- 1 S y 1 _-1 -7 a 1 Jai)1 k HIC Registration Number Expiration Date C Comp y Name or HIC RePG��stmn[Name Chi(_Zdsl-r'ciel- idr4 f(JfoO'2.Y'�y..Sefui'(eSCL o and Street mail address Como Iq clvw-u-S �11A nML3 9Z8-177-341b 4 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 .......... 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 K'P(1 � B V\Aq to act on my behalf,in all matters relative to work authorized by this building perin' pplication. �� -U" Cca r�.1 ut>° 2 i Pnnt Owner's Name(Electronic Srgnaturo� to 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 its true and accurate to the best of my knowledge and understanding. K�� E J`�4(A '20— Print Owner's or Authorized Agent's Naline(Electronic Signature) Dide 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/dps 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 SM.EI I, NLksSACHLSETTS BUU DLNG DEPART%WANT N• 120 WASH INGTON STREET, r FLOOR 0 TEL (978) 745-9595 FAX(978) 740-9W KI.xIBERLEY DRISCOLL MAYOR THomAs ST.PIERRa DIRECTOR OF PUBLIC PROPHRTY11WI.DING CONMUSSIONER 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 I I L5 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 l 11, S 150A. The debris will be transported by: (name Atif haule ) The debris will be disposed of in : gVokAA�tr � (© At (name of facility) (address of facility) � � f signature of permit applicant CZ date debrisalf..dw Massachusetts -Department of Public Safety I I '-- — `--- q Board of Building"Regulations and Standard§ Unrestricted•Building$Of any use group which -tonstructiun Supen iwr Contain less than 35,000 cubic fbet (991m1)of License: C19-091000 enclosed space, KEITH B KIDGER-` D NVERBRAD TRAE 1923 DANVEtIS MA I1t939 „ NO Failure to possoss a current edition of the Massachusetts Expiration f State Building Code Is causo for revocation of thls license. Commissioner 0412112014 Roe cps lie®nsing Infarmallan vIeIC www,Mi ss,Gav/0p5 �e rpavmunveuse.. o-P///�aa cc�ttdelYJ i t�ICenBe Or r0 Iatratl0n VOhd for IndIVId01 U90 Onl Office of Consumer Affairs&Busl ess Regulation i 6 Y ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: I e91etretlon: 154177 . Type: Office of Consumer Affairs and Business Regulation xpiratlon: 2113l2015 Individual 10 Park Plaza-Suite 5170 KEITH-8 KIDGER Boston,MA 02116 R KEITH KIDGER +r /J 27 BRADSTREET AVE: DANVERS,MA 01923 Undersecretary Not velld without a gnature i �4