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35 GREENWAY RD - BUILDING INSPECTION (2) . 1 / 'O Q The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards J Massachusetts State Building Code, 780 CMR. 7'"edition Budding Dept rf Building Permit Appli on To onstruct. Repair, Renovate Or Demolish a One- or T 'o-Funtils D" 'hng tWction For OWiicial Use Onl d Date Applied: C ' d 24 -v 1�— dings Date ON 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Number 3s &1eFC-1y4z1- V/ X1) 1.I a Is this an accepted street''yes Map Number Parcel Number _ no 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq Il) Frontage(9) 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.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if vesE3 SECTION 2: PROPERTY OWNERSHIPt 2.`j�\Owners of Record: ` /�;R rCy L61 Address for Service: me(Print) q79 -- 7yy s? liSa Signature Telephone SECTION l: DESCRIPTION OF PROPOSED WORK'(check ail that apply) New Construction❑ Existing Building❑ wner- OOcupied ❑ R cepairs(s) ❑ 1 Alteration(s) ClAddition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other O'S—pecify: O— Brief Description of Proposed Work': ION 4: ESTIrC3 ED CONSTRUCTION COSTS ated Costs: Official Use Only EEM and Materials QQQ Building Permit Fee: $ Indicate how fee is determined: tandard City/Town Application FeeTotal Project Cost'(Item 6)x multiplier x 2. OherFees4. Mechanical (HVAC) List: 5 .Mechanical (Fire S Total All Fees: S Su ression Check No. _Check Amount: Cash Amount:_ 6. Total Project Cost: S QQ(� ❑ Paid in Full 0 Outstanding Balance Due: t SECTION S: CONSTRUCTION SERVICES S.r,1 Licensed Construction Supervisor(CSL) /0if/NJJ /1 �/q _ 77 ..cc A400 / License Number Expiration Date N.;poc of CSL Hylder pT List CSL T �� - 7 ll'l J Type(see lkluw) Address -b AM 017.C7 type Description U I Unrestricted(up to 35,000 Cu. Ft.) Signature , , ' R Restricted I&2 Family Dwellin //.✓q-7/ Q M I Slawnry,Only RC Residential R;ofmX Covering Telephone 7 �j p� n w'S Residential Window and Siding /- '7 ( ( V— o�C7 ( �V 0 4 Sle Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 R stered Home improvement Contractor(HIC) �Af7� �o� ISO c77 HIC Compy N or HIC Registrant N �Gv jr RegistrationNumber Address �7'7/2 2 Expiration Date Signs Telephone �� SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.1 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 ...........0' No........... O 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. pConstruction re of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION //_< � as Owner or Authorized Agent hereby declare statements and information on the foregoing application are true and accurate, to the best of my knowledge and meo tier or Authorized Agent Date`un r the ains and nalties of (uNOTES: Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor t registered in the Home Improvement Contractor(HIC)Program),will W have access to the arbitration gram or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and struction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively. 2. When substantial work is planned, provide the information below: Total floors 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 halfbaihs Type of hearing system Number of decks/.porches Type of cooling system Enclosed Open 1. "Total Project Square Footage"may be,uhstituted for 'Total Project Cost" CITY OF S.U_EA%I, �tL-kSSACHUSETTS 9L IIDLNG DEPARTTILN-r :, •""•:"I20'WAiNINGTON STREET. )to FLOOR TEL (978) 74S-959S F.ut(978) 740.9&M KI.,[l)ERj_EY DRISCOLL \(AYOR Triomu ST.PIEm DIRECTOR OF PL BLIC PROPERTY/15t:MDLVG CO%L%USSIO%ER Workers' Compensation Insurance ,% Mdavit: Builders/Contractors/ElectriclansiPlumbers >nnlicant Information Please Print Legibly Naine' (Busincv.Ortvl,nriomindav,dual):'M� Address: city/state/zip:&/l�i7/0 �� 0/7S7 PhoneN: 77 oV90A0.2. Are you an employer'Check the appropriate box: Type of project(required): I.,❑'fam a employer with 1 4. ❑ I am a genital contractor and 1 6. ❑New construction employees(full and/or part-tune).- have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheep : 7. Remodeling .,hip and have no employees Them sub•contraewes have {. ❑ Demolition workingfor me in an capacity. workera'comp.insurance Y P tY• 9. ❑ Building addition I No workers'comp. insurance S. Cl We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right orcxemprion per MGL 11.0 Plumbing repairs or additions myself.(No workers'comp. C. 152,41(4),and we have no 12.0 Roof repairs insurance required.)t employees.(No workers' 13.❑Ofher, comp. insurancetequired.J -Any applicant that crab has 01 must abv fill Nn Ita seaian bat"Anaing three wortrsa'carrtpsnaation pinery inlarm dots 'I I.vtwiswtwta who auhaul this affidavit indicating they M doing all work and than hue outside contractors most mhtnil a new amdavh indics iq awk. =C.ntr:ton that cheek this Act mud anwhad an additional ahatl+hawing an name of Ito Ad,K Mftacwv and their woabn'cony.policy inramniaa /am an employer that b provid/nji,workers'compenaadon Insnroaee for my employees, Belgw ls the paBcy and foe rigs information. p n ,/ Insurance Company Name: �vt/��� �1 7/D'11 Palicy, N or Self-iris. Lic.N: Expiration Date: f I�2/ tub Site Address: City/StatdZip: /5 A ,tittach a copy of the workers'compensation policy declaration pap(showing the policy number and aspiration data 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 S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fits of up to S250.00 a day against the violator. Ile advioal that a copy of this statement maybe forwarded to the Ofrice of I it vets i gat iona ul die MA for insurance coverage vcri tication. /da hereby carfify raider the pain at d pens//es of perjury that the informalloa provided above is qua and correct <Io.t t r , 1pinn Dale: .A -�•' da P!or, 4: — .� 0d 0 O1ririal oat amdy. Da not write in this area, to he curnpleted by city or town n/flriaL i City or futon: ecrmivIlccme N 1%suing Authurtty (circle unc): i 1. Ituard of Ilrullll 2. Ruilding Department i.City/rown Clerk J. Electrical hnpcelor 5. Plumbing Inipeetor 6. Other C"nllact Pcrion: _ ._ . . Phones: _,_.. ....._ y CITY OF SALEM PUBLIC: PROPRERTY DEPARTMENT Construction Debris Disposal Aflid.nit (re(Iuired Ii)r all demolition asld reno%mion work) In accurdance 11 ali the sixth edition of the State Building Code, 780 CAIR Section I 115 Debris, and the provisions of.NIGL c 40, S 54; -� Building Permit N is issued with the condition that the dcbris resulting from this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by ,MGL c 111. S 150A. The debris will be transported by: /a7� !/.1�L>l— ILA ©JA9 Inane ul hitter) I he dcbris will be disposed ufin I name ul Iauluy) - I�ulttrc<. u(I�c dnvl a n we ut pi nnn .y+p iu nt Isle ;INlassachusctts- Department of Public Safetl 0Board of Building, R e eulations and Standards . Copstruction Supervisor License License: CS 102403 ng. Restricted to:, 00 .- WILSON VALDEZ 151 MAIN STREET MILFORD, MA 01757 Expiration: 11/20/2012 Tr#: 102403 �. ✓/fe ilam/na�lU�eaUR'o�✓dStaadaros; " it .�\ Board of Building Regulatiooa and Standards HOME IMPROVEMENT CONTRACTOR. Registration; 15057Z. Expifa lom 4P 112010 Trill268674 !i - TYPe D�Ai r I MASTERROOF WILSON VALDEi l 42 MAIN ST LEFT `` �o MILFORD, MA01757 Administrator