18 GENEVA ST - BUILDING INSPECTION r
The Commonwealth of Massachusetts
Board of Building Regulations and.Standards CITY OF
Massachusetts State Building Code,,780 CMRRECEIVEO �S SALEM
1gCTIONAL SERVI geVisedMor2011
Building Permit Application To Construct,Repair,Ra e Or Demolish a
Otte-or Two-Family Dwelling 2 4
This Section For Official Use
Building Permit Number: Date Applied:
Building Official(Print Name) Signature ate
SECTION 1: SITE INFORMATION
1.1 Property Address: �} y 1.2 Assessors Map&Parcel Numbers
I t% r Q✓leut. (ll r"-G21
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(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❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
"T)ti0.LsP 'DMIo n 5 Stir`�t. , ,✓l�, o«ioo
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : t `
f VL
713
iL
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: ETA
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �(� �� 11 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Cs—66-7Zb j '{ -7 1
License Number Expuation ate
Name of CSL Holder
2O1
List CSL Type(see below)
���e.- rS "
No.and Street Type Description
/ . J /� Unrestricted(Buildings u to 35,000 cu.ft.)
t rJP"'�i�y 4 �V\La. O I 1 Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
p�� 1 i SF Solid Fuel Burning Appliances
q76— yL-7— 33J I Insulation
Telephone Email address D Demolition
5.2 Registered Home Impgqrovement Contractor(HIC) i87 ZZ j 7 30 /(P
U\G'('lM, l �.wf'F�JI tG"^ HIC Registration Number Expiration Date
HIC Company Name or HIC Regishant Name
No.and Stre �r - "/7� pL.?—q,�,l.� Email address
City/Town,State,ZIP u 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
I,as Owner of the subject property,hereby authorize A `C,s LAK+ tr ir^-
/ to act on my behalf;in all matters relative to work authorized by this building permit application.
�'r,� 0 rA-veils d qk
PnnPnn"fMiYer's am Iec c rg ne) 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 accura/ate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signatu 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(IHC)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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/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"maybe substituted for"Total Project Cost"
CITY OF SME. i LA SSAMUSETTS
BUILDING DEPARTSMvT
120 WASHINGTON STREET,r FLOOR
TEL (978)745-9595
FAX(978)740-9946
KIMBERi RV DRISCOLL
tiIAYOR THOMAS ST.PWJM
DIRECTOR OF PUBLIC PROPERTY/BUIIDCVG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
dame(Busins&Orpnization/Individual): ►Cc.��k, l..t�v�. rt
Address: SOU I f� � &r "
City/State/Zip: o l 5-r L4
Phone 5Z7
Are you an employer?Cheek the appropriate box: Type of project(required):
1.0 1 am a employer ith � 4. 0 1 am a Seminal contractor and 1 6. E New construction
employees u ndfor part-time).* have hired the sub to contracrs
2.0 1 am a sole proprietor or partner- listed on the attached shceL t 7• ❑Remodeling
ship and have no employees These sub-contractors have S. demolition
working for mein any capacity. workers'comp.insurim
9. 0 Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its Ill.[]Electrical its or additions
required.] officers have exercised their
3. 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 13.0 Other,
insurance required.]
.—]1•Any applietm that chocks box bl mast a*o fin out the scrim below showing their workers'mnpmsad-policy infumtatioo.
*I Iawrsottrttna who subotit this affidavit ittdintmg they ate doing all work and them hire otaside cam eton met abmtl a tttnv amthvil irtditatittg such
'Cwtttocton that cheek this box must anached an additioaxd shoo showing an name of the and the*workers'comp,policy infasecaloo.
I am an employer that is providing workers'compensation Insurance jot my employees. Below is the policy and jab site
information. �
Insurance Company dame:_ In o41/ L/I
Policy 4 or Self-ills.Lie.tl: �I� W C L5 ?�-1(00 Expiration Date: wi
Job Site Address: 6 6 e✓ye u4. er/� City/Statef2ip:
Attach a copy of the workers'compensaHoo policy declaration page(showing the po ft number and expiration date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 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 ropy of this statement may be forwarded to the Office of
Investigations or the DIA for insurance coverage verification.
y do hereby certify under rite pains and penaties of perjury that the information provided above is true and correcL
Si•n t
Phone M -7 —
Official use only. Do not write in this area,to be completed by city or town oriciaL
City or Town: PermttILIcense N
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other,
Contact Person.• Phone it•
r,,• QTY OF SALEM MASSACHUSEM
l � BUILDING DEPARTMENT
120 WASHINGTON STREET,3m FLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR TY omm STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Sign ure of applicant
Date
I
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-007285
EO ��
FRANK D RAFFAC
STR
HALE MA 619
BE MA
BEVERLY 0191
„,n"s Expiration
Commissioner
04/07/2016
,,AA�_• C-��zeJ�p'aruca�o��aa.�aclueoelt.tea\ Officeof Consumer Affairs&Business Regulation
OME:IMPROVE. ENT CONTRACTOR
e9istrahon: ;�j07225 Type.
Expiration:: 0" DBA
RAFFA CONSTRUCn�ON , `' -- 40 Y
Frank Raffa -
801-Hale Street {i j
Beverly, MA 01915. -' -
Uuderseeretary
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