10 FOSTER ST - BUILDING INSPECTION (2) I'he C'unununwe;dth of Mussachuscits
-Hoard u(13uilJing Regulations and Standards CFry OF
Massachusetts State Building Code, 7SU C NIR SALE\I
13uilding Permit application To Construct. Repair, Renovate Or D• o t Is a
One-orraw-klimill Dnellin,V
This Section Fur Official We Orel
Building Permit Number: Date Applicd:
ILiilding 011lcial iPrini N;une) Signalu Dote
SECTION 1:SITE INFORNIATION
1.1 Proper! AJdr ss: 1.2 Assessurs %lep S Parcel Numbers
I.la Is this an acre ted street? es no Map Nunt(er ('arcul Number
IJ Zoning Information: 1.4 Propeaty Dimenslons:
Zoning District Proposed U w Lot Area(sq II) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.I.c.40. 134) 1.7 Flood Zone Informallon: 1.3 Sewage Disposal System:
Zone: Outside FloodZune?
Public Private O — Check if yesO I Municipal O On site disposals)stem O
SECTION1: PROPERTY OWNERSHIP'
2.1 \ rto— -17—dt \ \1 e_�� fnQ OIQy9
�e i�Q n Z E'IZ� M t CSC'_)
Mane(Print) City.State,ZIP
7 R EfS5 Jl 5-V 97B s- 6Sy
Nu.:md Street relephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Owner-Occupied O Repairs(s) O Alteratlon(s) ❑ 1 Addition O
Demolition O 1 Accessory Bldg.❑ I Number of Units_ Other a Spceiiy:
Grief Deseri tion of Proposed \Nark': M l�
SECTION 4: ESTL\IATED CONSTRUCTION COSTS
heat Estintated Costs: I OMNI Use Only
ILabor and \lnerials)
I. Building S 30 000 I. Building Permit Fee: S Indicate haw fee is determined:
2. Electrical S O Standard City+Tussn Application Fee
O Totnl Project Cost l item 6)a multiplier _ -- x
). I'hunMnS S ,. Usher Fees: S
J, \lahanical ill\ \C) S List:
c %fechanic.d iFira ----- ----- - . . .
Cat rression) S ratarkii Fccs: S_.._ —
Chcck No. _Cheek AinkIIrm: C.tsh Utomit:
0 1'uwl I'rnjcct Coo: S Q Q00 0 Paid in Full ❑Oulst:mding Bal ice Duc:
r '
SEC 1*1ON S: CONtirRUCTION SERVH ES
S.I Construction Supcn�isur License(C'SI.)
r. .....i '. 1. (�.. .� I Iccnae Numher r�1 iraliou Dale
N.unc,+i l'SI I InlJcr I ut('St. I')pe(Sev 116ml._
�v__ v�q_ e _S _ _.—__ I)w Description
Nu. .ntJ sued tl Ihtrestrioed lluddin s L1.0 In 14,I111Q cu. Il.l
It ItatricicJ IA! F.anil 11%%e11i'1
Cihifoen,Stale,Lll' ,\t 11;uuu
HC Htanin Cuccrin
Ws \v'induw.tnd Sidin
g 8�7 solid Fuel Ilurniny Appliances
1 l
I Insulation
l'cle hone h:mail aJJrcaa D I Demolition
5.1 Registered flume Improvement Cuntntctor(HIC) / 70�6 as
P ov
e 0 \ ` I Cl() Z: I, 111C Itegistnuiun M11111 r .vpin lion DWY
I IIC'Coln 1 Nanly orJl(C Regisuum WIIY �M:SPA 1U 4 ' -�+o
� Vc�nz \ �LJ\I��1cD0
. ;old Strict C,t•r�JerS Inl:muil address
M
Ci /T wn,State ZIP c e hung
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L it. 132.1 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 .......... O No...........0
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 Uw wr's Nwne(Elcorunic Signature) Dula
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
containe this application is tr ind accurate to the best of my knowledge and understanding.
Print Uw net'. n:\uthorireJ.\gcnt's Nunes Ihacetnmic nawre) Date
No rEs:
1. An Owner whu obtains a building permit to do his.her uwn work,or an owner who hires an unregistered cuntnwur
(Trot registered in the Hume Improvement Contracturl HIC) Program).will nr have access to the arbitration
program or guaranty fund under\I.G.L.c. 11?A.Other inipurtant information on the HIC Program can be round at
I information on the Conslruclion Supervisor License can be found at
? \\'hen substantial %York is pLutned, provide the information below:
rotal flour area uy. ft.l , __ t including garaya, finished basement attics.Jacks ur porch I
Bross living area(Sy. Il.l _ Habitable room count
\un+t+crof fireplaces .... -_. . . Numberofbedrooms _ . . . .
t Numher of hathrroms — J_ \weber ul hall holhs .
I)lie of 1leating s)itoll Nunlher ol'Jccks porches
� 11 pu„t e0%`111Ig i\Aelll 01+en
1. Total Prow \%1u;IrC 1'111m�1L'C'•IICI\ he sob%niwcJ t1v"RIta11'mjecl Coat"
CCI•Y OF SA\L.E.M. NWSACHt;SETTS
l UL'ILDL\G DEP.+Rr�IE�T
120 WASHLVGTON SHEET, Jog FLOOR
-9595
ILL978
( ) 745
F.kx(978) 7$0.9844
,v.\113(Zt RY 0RISCOILL THOsusST.PIER"
ALSYOR
DIRECTOROF PUaLIC PROPERTY/13LACING CO>LUIISSIONER
Workers' Compensation Insurance AfRdavit: Builders/Contructors/Electric(ans/Plumbers
kimile ant infnrm•rtinn Please Print Legibly
Name IHueiixsUrl;,tmralian,Individual ^^): �- �a 1 ' Z- i,
Address: G7
City/State/Zip: 5 MQ Phone .N: 973 `PJS�I��J�
,kre yi)u an employer?Check the appropriate box: Type of project(required):
1.0 1 am a cmployor with 4. Q I am a general contractor and 1 5. ❑Now construction
nipinyea(Nil and/or part-time).• have hired the subcontractors
2.Eel
am a sole proprietor or partner. listed on the attachad sheub t 7. (j(�Remodeling
.hip and have no employees Those sub-contractors have g. ( Demolition
working for me in any capacity. worker'camp.insurance. y, Q Building addition
(No worker:comp.insurance J. Q We are a engroration and its
required.) officers have dxareised their 10.0 Electrical repairs or additions
J.❑ 1 an a homeowner doing all work right of exemption per MOL 11:0 Plumbing repairs or additions
myself. (No worker.Bump. c. I52,4t(4).and we have no 12.0 Roof repairs
insumned required.) t employees. [No workers' 11.0 Other
camp. insurance required.)
.lolly aPptluol IIW dtwks boll rI mw1 alp.fill Out the waioei bulow.howing their wmlan'e.mpensatun Poky mdlrmallon.
'I6vnvowm-na who whniil Ws_sifilovii Indicalna they am doing all work and then hits witids...tractdrs mtw m,len11 s now 3171davil indicting 4wit.
!(%mmrtun that Owe this box owl auachad in iaditiunal.hsi�huwing the nulne*(the suboillaresvers,and their work.rs'Gump.policy inromwnae.
I ma an emrpluyer that lr pruv/dlax workers'cumpe araNua/nauronet/or my emp/ayeest Below/x the pol/ry sad jab ills
iu/arnruNna, . e
In.,urtice Company.Name: U-RPr—,- _._I-_21 (V��C�Q-
Policy 4 ur Selr-its. Lie. d: W C 67 3 � "�7��� Expiration Data: 1 8y 01 (,
)ub Silo Address: /� Cilyistate zip• dl 7 70
Attack a copy of the workers'compensation pulley declaration pails(showing the policy number and expiration data).
Failure to,scum cuvdraga us required under Suction 2Jrk ut•bIOL c. 132 can lead to the imposition of criminal penalties of a
rirc up to i 1,J00.00 and/or one-year imprisonment,is well as civil penalties in this farm of STOP WORK ORDER and a tine
ui up to 5!!0.(10 s day against rite viula:nr. IIe advised that.copy of thin.,tatvirient inay bQ furwardcd to Ilia 011lco of
Lt re,tig.lniuns�ti the DIA tar insurance covemye veriliraliun.
I du hereby card/' uder 111r pains old altl%a/perjury allot the inj6rarurlurr pruviJrd uGuve i..trot•urJ rorrrrR
vi: 1 >a
rr�e,r:
UIlicial u,e Andy. Da nor write it,this area, to be completed by city of town ofjlria!
Ciry or Town:____. .. .__ l'l'fmltll.lccnae i__,
1„uiii- Aulhurily (circle h ac):
I. Iiu:Rd ul Ile.lth !. I11jildlm4 1).•p-aihoenl .I. ('ityi four Clerk 1. Iileetric.'I Impcctor i. Plonibind Inlpectot
�'. Cn�tlait I'e rtno: I hone .1;
CITY OF S.1L ENII ►bL1SS.ICHL:SETT3
JCtl�LVC DEP.IATtEVT
1 _'0 '.V.U-4LVGTON STXW, J`FtOpA
� I1rL �97� 1�5-9593
.'UJ®ERLfiY DRLSCOLL P�X(978) 1149846
MAYOR tkow�Sr.Ptz�u
DIRFGTOAO/PlHLICPROPlli7Y/BCQDLYCCO.AL JtONFA
Construction Debris Disposal Affidavit
(required for all demolition and
renov
ation wo
rk)
In accordance with the sixth edition otthe State Building Code, 130 CMR section 1 I I.J
Debris, and the provisions o(,,MGL c 40, $54;
Building Permit Al is issued with the condition that the debris resulting from
I f, $ IJOA.work shall be disposed of in a properly
i Il licemed waste disposal facility as delincd by NIGL c
The debris will be transported by:
�� C Z. 'nlfCn Sonl °
(name ufhau er)
The debris will be disposed of in :
in of 4a,p,y)
A'e"'e h,N C s /e
I,Jaraf, urn„I„y)
r'
,ynarur afpermit ,pp6c,nf �����?��