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0005 HARDY STREET - BPA-12-655 f_ � The Commonwealth of Massachusetts IYII a Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CM R SALEM RevisecLMar 201 Building Permit Application To Construct,Repair, Renovate r Demolish One-or Two-Family Dwelling This Section For Official Use Only t Building Permit Number: II, tt Date p ied: Building Official(Print Name) Sign Date SECTION 1:SITE IN ORMATION 1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers ..�f/9�ec�,� L la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning information: 1.4 Property Dimensions: i2Z .P�T5J®[S-.t 7//1G Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(It) 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? Municipals On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner[of Record: ,6,tF_a1,-ze* 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) i2$ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of ProposedWorkz:�_��oGnLE Prpltr /�eo i SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ oocoe 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: 5.Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ e-V 0 Paid in Full:' 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 9yZ 9© G-��s -�oiZ /J7/C�/AG'G �!/�PL[`$ License Number Expiration Date Name of CSL Holder List CSL Type(see below) G/ /i c� yro,✓ s r No.and Street Type Description C YnriC/' j`lf 0190 r, U Unrestricted(Buildings up to 35,000 cu.ft. I R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding ly/7 -Z67 SF Solid Fuel Burning Appliances I Insulation Telephone Email address r Cow/ D Demolition 5.2 Registered Home Improvement Contractor(HIC) /J7i4 .c%acF-s C'i1�2� �,� /S-3©ra io lc>-23->Z HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name // l'c10 yTont g7 Q2ir.0 S7��7iJ..a..i_ No.and Street 7- ZS7 Email a dress Ywn/ lY/li C3/�joZL /*q3 �eo�+i 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 ..........5a No...........❑ 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_/Yf/Ca//16L to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNERS 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 myknowledge and understanding. Print Owner's or Authorized Agent's Name(EI oni Sign re) ^� Date NOTES: I. 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.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"may be substituted for"Total Project Cost" i CITY OF S.UXM, 1NLA S&A CHL'SETTS BUILDING DEPARTMENT • A• 120 W:ISHINGTON STREET,3w FLOOR TEL (978)745-9595 FAX(978)740-9846 KI\BERLEY DRISCOLL MAYOR THOFtsis ST.P1ERRE DIRECCOR OF PUBLIC PROPERTY/BUILDING COSMBSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLriblv Name(BusimssiOrganizatiordindividual): Address: // G'09, Y City/State/Zip: 4 VA1^1 OY96!4 Phone #: a/'7�Z�7—/ Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.M am a sole proprietor or partner- listed on the attached sheet.t ?• 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 their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.[]Plumbing repairs or additions myself.[No workers'comp. c. 152,g 1(4),and we have no 12.❑ Roof repairs insurance required.)t employees. LAro workers' 13.❑Other comp.insurance required.] •Any applicant nun chocks box#1 most also fill out the section below showing their workers'compensation policy information. t I Inmeownrn who submit this affidavit indicting they are doing oil work and then hire outside contractors must submit a tens,affidavit indicating such :Comm,non that check this bone most attached an addiuomd about showing ato name of the sul>comta atxs and their workers'emnp.policy information. l am an employer that is providing workers'compensation insurance for my employees. Below Is the polity and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to suture 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby certify under the ulna and enahles o perjury that the information provided above is true and correct - . I tr • ��r� Date: ,?— Phone#: e-0 Official use only. Do not write in this area,to be completed by city or town of iciaL City or Town: Permit/Liceme# Issuing Authority(circle one): I.Board or Herlth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone If: CITY OF S. .&M, TNLksSACHUSETTS BUILDIING DEPNRT%ILNT N 130 WASHIINGTON STREET,3'n FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KI\iBERLEY nRISCOLL MAYOR D.10M s ST.PIEM DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER iER 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 c 40, 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 disposal 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 ture of Kermit applicant date dcbni. Mdm