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24 HANSON ST - BUILDING INSPECTION (5) 5072 The Commonwealth of Massachuse is Board of Building Regulations and Standar s CITY OF Wff�j Massachusetts State Building Code, 780 CNIR SALEM Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised,tkir 2011 One-or Tivo-Family Dwelling This Section ForAtRcial Use Only " Building Permit Number: D: eAp I 02 -1 Building Olhcmi(Print N;une), _ Si, Z SECTION 1:SITE INFORMATION / t2 perty Address: T�.�NS /p�v S.�/ 1.2 Assessors blep S:parcel Numbers I.I a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Tuning District Proposed Proposed Us�— Lot Area(sytl) Frontage(It) 1.5 Building Setbacks(ft) Required Front Yard Rewired Side Yards Provided Rear Yard Provided 9 Required Provided 1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: L8 Sewage Disposal System: Public❑ Private❑ Zone: — Outside Flood Zone? Check ifyes❑ Municipal ❑ On site Disposal system ❑ 2.1 Owner'of Recor SECTION2: PROPERTYOWNERSHiP' d: 7/ P-0 N it /� /�ZIP"NS, iune(Print) City,State,ZlP 5,4 L cru-7 1 ;7 Nu.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building[3cupi Owner-Oced ❑ Repairs(s)A Alteration(s) ❑ Addition ❑Demolition ❑ Accessory Bldg.❑ Number of Units_ Brief Description of Proposed � Work': Other ❑ Specify: Gt tii�G 2c= /+i2 sr/li✓2 Z7/C i � -- SECTION 4: ESTfiN ATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only I. Building S (.�v I. Building permit Fee:$ Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee 3. Plumbing _ ❑Total Project Cost'(Item 6)s multiplier x 2. Other Fees: S 4. Mechanical (FIVAC) S List: 5. Mechanical (Fire Su ressimn) S — Total All Fees:S 6. Total Project Cost: S /' "' Check No._Check Amount: Cash Amount: 7.J ❑Paid in Full ❑Outstanding Balance Due: NtAtL D C_oKyTr G�a1 $S-7 _ Z__7 -Z t�60 k�(o -7S ( - (, 5q 1-7-11 SECTION s: coivsraucTloSERVICES 5.1 Construction Supervisor License(CSL) Expiration n el License Number n J Nome of CSL I[older List CSL Type(see below) 3 6 v qA, S/ Type Description No. :mJ Street U Unrestricted Bottom so to 35,000 cu. tlJ i Q2 / / R RestrictedI&2 Fanil Dwellin bl Mason Citylrown,Slate,ZIP RC Roolin Coverin WS Window and Sidin SF Solid Fuel Burning Appliances �j2 c, /0 3 I Insulation� O(� p Demolition Tele hone Email address /63339 ��/ 120' 5.2 Registered Home Improvement Contractor(HON I[IC Registration r Expiration Date HIC Company Name or HIC Registrant Name /`74 C, 1 3� ✓ A--S ` �r y 3 Email address No.and Street , /"'7� D2/T/ f39?�LVJ Tele hone Ci /Town,State,ZIP - SATION INSURANCE AFFIDAVIT(N7.G.L.C. 152.§ Z?C( SECTION 6:WORKERS'CONIPEN . 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...........❑ CTION?a:OWNERAUTHORIZATIONTOBECOMPLING PERMIT WHEN: SE " OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 1,as Owner of the subject property,hereby authorize 4 �r/G� iS tq act on my behalf,in all matters relative to work authorized by this building permit applicatior. 2 /J 7'/�tl 1-1/ 0`% i/�/ Date " Print Owner's N:une(Electronic Signature) 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 t e best of my knowledge and understanding. ^ � n O1/pz.140,1�'. A r /1 c 4 /�79✓L��� D;ae c ) Print Owner's or Authorized Agent's Name lLk NOTES: to er ires an egistered 1 (An not registered in the s a e improvement ing rmitContractor(FIIC) Program)his/her own worK,or nw llni�txhavvenaccess tonthe arbitration tractor program or guaranty fund under�LG.L.c. Id2A.Other important information on the H[C Program can be found at www.ma_ s_ i_ "t w�-uct information un the Construction Supervisor License can be found at www m_ t-."�Y'`_IL�ti rGross When substantial work is planned,provide the information belng oar�ge, finished basement/attics,decks or porch) l floor area(sq. ft.) Habitable room count living area(sq. ftJ______---- Number of bedrooms Number of fireplaces Number of half/battu ,Number of bathrooms Number of decks/porches Type of healing system�— Enclosed TypeType of cooling system 3. "Total Project Square Footage"may be substituted fur..total Project Cost" CITY OF St:=Nl, NLNSSACHUS.ETTS S Bl:1IDING DEP.AR:rSt&`iT H 120 WASHNGTON STREET, 3'a FLOOR "ICY- (978) 745-9595 F.vr(978) 740.9M KI\BERL.EY DRJSCOlt �YAYOJt I?fOR1A5 ST.PI1✓4RE DIRECTOR OF PUBLIC PROPERTY/BCLLD[NG CON[MISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly NalnC r16�C' Address: City/State/Zip: 12-e—' 6'6�� Phone h: Are you an employer! Check the appropriate box: 'type of project(required): 1 1 am a employer Z_ 4• 6❑ 1 am a general contractor and 1 r oyer w ❑New construction entplayees(full and/or part-time).* have hired the sub-contactors 2.❑ lama sole proprietor or partner- listed on the attached sheet.t 7. EIyRcmodeling ship and have no employees These sub-contractors have S. ❑ 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 their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions myself. (No workers'cutup. C. 152,§1(4),and we have no 12.❑ Roof repairs insurance required] t employees. [iv'o workers' 13.❑ er m Other crimp. . •Any xpplivant out ducks box or most also rill out on:uclion below showing their wotken'compensation policy inlbrmatiun. 'I l,.eowncn who submit this affidavit indicating they ate doing all work and then hire outside contractors m na submit anew alRdavit indicating such. :cwuracturs Ihut check this box moot anached an additional sheet showing the inure of the sub.eentnctots and(heir workers'comp.policy inromsation. l ant an entplay'er dtut is providing tvorkeri'compeusadart iasurunce for my employees. Below Is the polfey and job site information. Insurance Company Name: Policy it or Self-ins. Lic.rl: U/ C S 3 /r Expiration Date: 62 4) ty/�of Job Site Address: 1 y Hp .(—.SO'e.., SIr City/State/Zip: SA LC '" Attach a copy of the workers'compensation policy declaratlan page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ot'41GL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as w'cll as civil penalties in the form of a STOP WORK ORDER and aline of up to$230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Oflice of Invastigtuious of the DIA for insurance coverage verification. - Ida hereby certify under the pains and penaltles of perjury that the inforrnatlwt provided above is true and correcL Si,znature' �l/1� �2oJ A// Date: �Z ��I Phoned: BS Zx 6--o 3 Official use mrly. Oo not write in this area,to be cuniplered by city ar town ojficlu[ CiryorTown: _----- .__ Permitil.lcenset{__.._ ._—. , Issuing Authority(circle one): I. Board of licalth 2. Building Deparnatent J.Cilyffnwn Clerk J. Flectrical Inspector 5. Plumbing Inspector 6. Other . . _. I Contact Person--- _. .. _ Phone [ S CITY OF S:U EM5 ASSACHUSETrS t ©umDL\G DEP. m-n0NT 120 MASHLNGTOY STREET, 3-10 FLoOR T-..L. (978) 745--9595 KIMBERT Y DRISCOLL FA-v(978) 740-9846 NLAYol; T HoaLAs ST.PmRRa DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CON L1t155IONER Construction Debris Disposal Affidavit ` (required for all demolition and renovation work) + M k.i.J In accordance with the sixth edition of the State Building Code, 730 CMR section I l•`.5 Debris, and die provisions of MGL c 40, S 54; Building Permit A is issued with the condition that the LZ debris esulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by' c 111, S 150A. The debris will be transported by: ti 9 �vMPS7Z�2 (name ofhartlor) The debris will be disposed of in --- -- (name of facility) -----(address of tacility) signarura of permit applicant plate