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49 HAWTHORNE ST - BUILDING INSPECTION cK b�+S2 $23� Tom- LA 8 ( S C� -� r Il7'bs ECEIVEO t The Commonwealth of blassadld6RiP CITY OF pl6 Board of Building Regulations and Standards 5 5 SALE;NI iVlassachusetts State Building Code, Wo 22 A Revi.red.t/ur 2011 1� Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Only Building Permit Number: Da Applied: Building ORicial(Print Name) Signature Date SECTION 1:SITE INFORNIATION' 1.1 Propert Address, 1.2 Assessors Ninp& Parcel Numbers 1.1a Is ac,�T1 ad h tt Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sy tl) Frontage(I1) f 1.3 Building Setbacks(ft) Front Yard Side Yams Rear Yard Reyuired Provide) Required Provided Required Provided L61Vnter Supply:(M.G.L c.q0,§Sd) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ ( Public❑ Private❑ Check If es❑ P SECTION 2-. PROPERTY OWNERSHIP' 2.1 Owner'of Record: Sq terti rv-\C, U IQ )G „ )y Qc�eS NN arse(Print) City,State,ZIP �L No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED 1VORIe(check all that apply) New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Brief Description ot'Proposed\Vorkc: 0 1, 'aw-1 h,.k new hrO*C,.rn and bo+h oP if, 2 :�s\\\S qc drAXa% ao Pl4�S SECTION 4: ESTINIATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials) I. Building ; I. Building Permit Fee:3 Indicate how fee is determined: ❑Standard Cityrlbwn Application Fee 2. Electrical S ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S :1.Mechanical (FIVAC) S List: i i. ,McchanicoI (Fire S 'Total All Fees:S Su ressiun) Check No._Check Amount: Cash Amount:_ 6. Tutai Project Cost: .S 3a ❑Paid in Full ❑Outs»utding Balance Duo: - ;I M�t L (D Lt/Z'] �E �, � �� 0vi��an _'C SECTI6N''5W�C0NS'fI1UCTIONSERVICES 5.1 Construction Sapetvlsor License(CSL) -S— S 895 ��7 A SS � ;� f�t'�i License Number Expiration Date Name of CSL Holder List CSL Type(see below) Ga q 1'CAr4 S rype Description No.and Street �� Q\ci 70 U Unrestricted Farm(Buildings tip toing cu. tt. Sq kPv'1 R Restricted 13t2 Family Dwelling i CityfRmn,State,ZIP bl Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances r I I Insulation Tole hone Email address U Demolition 5.2 Registered Home Improvement Contractor(HIC) S a6C/ro ag/ 14 (je,C'm HIC Registration Number Expiration Date H C Coll ly Nnme or HIC� Registrant Name a. I,S, reaee s� � N� and Street 4 Email address cityrrown,State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NI.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 Isivance the building permit. Signed Affidavit Attached? Yes .......... No...........Cl SECTION 7a:OWNER AUTHOIRIZATION:TO BE COMPLETED WHEN; " OWNERIS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize t9 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:OWNEW 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 ' true td accurate to the best of my knowledge and understanding. Print O tF. or At toriteJ Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do hisllier own work,or an owner who hires an unregistered contractor (not registered in the home Improvement Contractor(IIIC) Program),will no have access to the arbitration program or guaranty fund under\I.G.L.c. I42A.Other important information on the HIC Program can be found at �eww.nrass. •ov:'oea Information on the Construction Supervisor License can be round at www.mass. •ov'dL 2. When substantial work is planned,provide the information below: rotal floor area(sq. 11.) (including garage, finished basemenNattics,decks or porch) Gross living area(sq. It.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number orhadf➢baths Type of heating system Niimberurdec"porches Fype of cooling system Enclosed Open 1. '•roial Prujcct Square Fourtgc"may be substituted tor-r,tai Project Cost" i CITY OF &U-ENI, ti'LNSSACHL'SETTS ' BUILDING DEPART EINT ,3 4 1t 120 WASHLNGTON STREET, 3w FLOOR T EL (978) 745 95 S FAx(978) 740-9846 iV.\BERL•EY DRISCOLL MAYOR DIRECTOR AS ST.PIFaxs DIRECTOR OF PUBLIC PROPERTY/BUB.DLNG CO\NISSIONER NVorkers' Compensation insurance Affidavit: Builders/Con true tors/Electricians/Piumbers Alinlicant information / / Please Print Legibly VamC(t3usincss Organizatit)wlndividual): 6ky,\ `Qvvytt'� L GfarvPRi\ COn)VI A,-�Q Address: City/State/Zip: -Pq\fw\ N\q. O197cs Phoney: C07q Arc yt an employer?Check the appropriate box: 'type of project(required): I. I am a employer with_� �• ❑ 1 am a general contractor and 1 6. El New construction employees(full and/or part-time).* have hired the sub- contractors 2.❑ 1 ant a sole proprietor or partner- listed on the attached sheet.t Z ❑ 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.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [10 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 cut checks but AI most also rill out the section baowshowing their workers'compensmion policy inllimatiun. 'I Luneuwnsrs who submit this anldnvil indicating they are doing all work and then hire outside conimetors most mthmil a new affidavit indicuing such. ('nttmcwrs Out Owl,this box most anachal an additional sheet showing the none of the tub-camneton and their workers'comp.policy infomution. I our an employer that is providing workers'compeasatlors hisurance for my employees. Below Is the policy ondJab she information. 7 '"'��I (� Insurance Company Name: &&e � �/�— /CI Apr•-f. �p(f Policy A or Self-iths.,�L//iee.. it: -__„— Expiration Dater Job Site Adehess: `Y / ��4,...'F��>�2 �-� City/State/Zip: J9)ta, ✓ ci, <11(00 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 tine up to S1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to S250.00 a day against the violator. lie advised that a copy of this statement may be furwarded to the OI'lice of Investigations of the DIA for insurance coverage vcri lication. I do hereby certify( rur�der the pains wad penalties of perjury that the information provided above is true and correct S�Itue' f ��(y - 1 Dare: '7�aa adJ OJJic•iul use only. Do not write its this area,to be completed by city or town oJJh•ial - CitvnrTown: ____ .__ Permit/Licensek Issuing Aulhurily (circle one): 1. Board of Health 2. nullrling Department .1.City(fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: ... __ Phone r2: ��}vr CITY OF S'u.E�i, 1NL1SS.ICHUSETTS _! ©1:ILDL�IG DEPAR , L&NT 130 WASHLYGTON STREET, 31O FLOOR TEL (973) 735--9595 Floc(973) 7-10-9946 K11BF_RLEY DRISCOLL &LAY0:1 T�tOSLAS ST.PMRIM DIRECTOR OF PGBLIC PROPERTY/BCU-DLN<;CO\pt155IONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixdt edition of the State Building Code, 730 Cp fR section It 1.5 Debris, cuid the provisions of tbIGL 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 NIGL c 1 11, S 150A. The debris will be transported by: k. lf (namc of hauler) _ The debris will be disposed of in -- — (name orfaci ity) — 4 _ srgnamre vfpermit applicant I rl.uc -- 120 — SECOND FLOOR Scale: 1/8" = 1'-0" 8' o" sitting 33 0" -- --------------------------- - 'l 2 - 1 3/4"x 14" Ivls bolted.4 so 7Fz " ---------------- -------------p It typical N ca O 10' 5" dining -- dn ------- ------------' living oa .. - - up 'z4 solid 4x4 solid Q 22' 0" Post typical -__--___- 2- /4" x 1 " lv-Is bolt.ed. 0�st pica[ 33 0 ------------- -- - ------------------ ------------- - a'i Q 13' 8" porch � �----------- -------- --- 1-7� � � _ O —U_-- Q)CL I C C 10' 5" I >' U J C O kitchen ! 7LePD l n 9 4x4 solid0 '� rn 1 � � post type d a ° ° l j closet F= c`a c5u - - - - - - ' 2r- � r� � © X 0 7 I L O o bedroomlo' s° Torn bedroom � E 0 s Cu 2 aa) N ��tfn 4 Z 't Massachusetts -Department of Public Safety C Board of Building Regulations and Standard , Construction Supervisor License: CS-095895 JORN J CAMIRE,-` 62 LAWRENC�,STREE SALEM MA 01970 � { Expiration - Commissioner 07/22!2014 + a � ✓/L6 100AtlNdA[/APQSIR O�✓�4%Qdd60�IE6� r Board of Building Regulations and Standards.!. - HOME IMPROVEMENT CON TRACTOR Ii 'Registration 152096 Explrailon 7/28/204U--3 Td!-27144fi,, #` Y. - JJC GENERAL CONTRA�TINO r JOHN CAMIRE 62 LAWRENCE STREET.. -SALEM,MA 01970 Administrator