28 GARDNER ST - BUILDING INSPECTION (3) Ts 2S a-b
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 A lied: f 1- -/J
+✓ �/
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property A 1.2 Assessors Map&Parcel Numbers
k' 2 dress:S CsA� az S'r 0
l.la 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(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: 1.8 Sewage Disposal System:
Public&P Private❑ Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerr of Reco
J� N d: SA uoscqo SALC- M , MA , 01910
Name(Print) City,State,ZIP
9fg3 -6►-19 san'toGy►�cr3 ccrn
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building It Owner-Occupied I)dl Repairs(s) 19 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units 2 Other ❑ Specify:
Brief Description ofProposedWork : Sw5fw11 E . ow' in e ,.. ,v�
rn mecl O , w G— f 6c
1 od
�aJb/Q 3Z 5- 'L e.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ / 000, 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$ i
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
Zb kAN615ow 2D Olq 23
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Z /
sz8 y
(11 ky,l`' ()r" License Number Expiration Date
Name of CSL Holder I
noL, (� 6 List CSL Type(see below)
?n L (l
No.and Street VAX Type
U Unrestricted(Buildings up to 35,000 cu.ft.
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
I!//A,, SF Solid Fuel Bunting Appliances
617 Z/Z S'M /TV/eAq,ePN tw/�A64/ 0&1 I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ��p�D r/ ,�. 7��5
6 1 �ib� t7S 011 H[C/Regis/tralion Number Expiation Date
HIC Company Name 4r HIC Registrant Name
No.and S et 0— Email address
bAA/Veas 4Aa . 0110 60 2(XoMr/
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....q......❑
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 (7/f'./I l 'Z(�H'l ;0 YL,
to act on my behalf,in all matters relative to work authorized by this building 6ermit application.
C�t2►ST�Rn� �. �,iS/k 1=1��;�ry �,11-5 -�Oi3
Print Owner's Name(Electronic Signature) 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
contained in this application is true and accurate to the best of my knowledge and understanding.
6 . (-77org ns -/v/L 11-4=13
Print Owner's or Autho ' d 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/bath's
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"
CITY OF S.U.E:tii,
2yLkSSACHUSETTS
' BUI DL\G DEPARTMENT
` 130 W.'ISHINGTON STREET,3ra FLOOR
a TEL. (978) 745-9595
FAX(978) 740-9846
KI\BERLF-Y DRISCOLL
MAYOR THoh1AS ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG CONMaSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aunlicant Information / / Please Print Le ibly
Name(eusim5 organi:ationiindividual): C:)Iey! I Nt o tf pS D�
Address: e0 L OALLo 9UX >
City/State/Zip: 1�NVCR-f M 0)9e 3 Phone#: G �7 / Z
Are you an employer?Check the appropriate box: Ty
1 Mi am a cruployer with Z_ 4. ❑ 1 am a general contractor and 1 pe f project(required):
employees(full and/or part-time).* have hired the subcontractors 6. E]New construction2.El [�1 am a sole proprietor or partner- listed on the attached sheet t 7. Remodeling
ship and have no employees These sub-contractors have 8. ❑ 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 thew I0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL t I.❑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' 13.❑Other
comp. insurance required.]
•Any applicant that d=ks bos#1 most also fill out the section below showing their workers'compensation policy information.
*I inmeownas who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicaring such.
=Commeton that duck this box must anached an additional short showing the name of the aab,,,n1ctsx;and their worker'comp,policy information.
l am an employer that is providing workers'compensation krsaranee for my employees. Below Is rke policy and Job site
information. � ,.� ��
Insurance Company Name:�le/,S C._Gt51,W OL,11 S,, ,y
Policy# � �a q8 i w9�z�� Expiration Date: Q �Z ZO/
Job Site Address:o`nn C6 l7/,A2171J Sr City/State/Zip: gtije.m
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 S250.00 a day ageins he violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations oI'[Ile fo insurance coverage verification.
I do Irere by rertl y nd the palms and penalties of per ary that the information provided above is true and correeL
l t t • fate: 14-4LI
P_htma#: Z/Z
Official use only. Do not write in tkLr area,to be completed by city or town offlcirlL
City or Town: Permit/I.icense#
Issuing Authority(circle one):
I. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: