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13 HAZEL ST - BUILDING PERMIT B-14-212 2. i2 - I I 2'1 I AIL Lf" (P(o (P 09 -03 - r 3 The Commonwealth of Massachusetts � Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR S ALEN Revised Mar Nnr 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Only Building Permit Number:' - to Applied: Building Official(Print Name). Signatur Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers ff r 1.1 a Is this an accepted street9 yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(R) IS 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: ly Public ' Private❑ Zone: _ Outside Flood Zone? Municipal On site disposal system Check if yes❑ fd SECTION 2; PROPERTY OWNERSHIP' 2.1 Ownerl of Record: t9./6 A) Hvrl eX ��me(Print) � City,State,ZIP N� !' s r No.and Street Telephone Email Address SECTION 3:.DESCRIPTION OF PROPOSED WORK'(check, I that apply) New Construction Cl Existing Building Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: SThl° Brief Description of Proposed Work': - erc Oo a SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ '�� °B 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: $ 4. iNlechanical (HVAC) $ List: 5, iMechanical (Fire $ Su ression) "total All Fees:S Check No. - Check Amount: Cash Amount: 6. "total Pro,)ect Oust $ ❑Paid in Full ❑Outstanding Balance Due: f SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ��7 " E"', „f Q ,b Le-e License Number Expiration Date to dCSL Holder List CSL Type(see below) � 3 CSSPX s Type., Description No.and Street et Vg V� �'q ©117 p4 D Unrestricted(Buildings a cu. R.) J ! R Restricted I&2 Family Dwelling Citylfowa,State,ZIP M Nfasonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D I Demolition 5.2 Registered dome Improvement Contractor(HIC) / -� ,Z,/ Za HIC Registration Number Expiration Dale Hli Cofrb my N me or CIIC Registrant Name No��nnd Strcet Email address ` -r r a____ 5 li/7 alp, 7L, Cif /Town,State,ZIP alp, SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.§ 2SC(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 tq 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,'( 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 my knowledge and understanding. / orro�h.��c.�ti�. 9/31zo / Z mint Owner's or Authorized Agent's Name(Electronic Signature) 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 loot have access to the arbitration program or guaranty fund under bLQL.a 142A. Other important information on the HIC Program can be found at www.mass.aov'oca Information on the Construction Supervisor License can be found at www.nrtss.sov."dns 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. If.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches "Cype of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"total Project Cost" :f CITY OF SM.E.M. 2ANsSACI USE-frS • BU umiNG DEPAR-ntENT N 120 WASHIINGTON STREET, 3' FLOOR `I EL (978) 745-9595 FA.s(978) 740-9846 KNtigFRt HY DRISCOLL i1�LiYOR THObfAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUILDNG CO\tsIISSIONER 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 it 1.5 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: :,l ! c f' rl (name of hauler) The debris will be disposed of in (name of facility) (address of facility) - signature of permit applicant dale debi'isai(dH: a CITY OE SM E1I, INLkSSACHUSETTS • BI:ILOL�IG DEPARTMENT 120 WASHINGTON STREET,3io FLOOR sae TEL (978) 145-9595 R.X(978) 740-9846 ;ti.NLBFRi RY DRISCOLL THOD1ASST.PIERRJ3 MAYOR DIRECTOR OF PUBLIC PROPERTY/91:QD4`IG COhLLti[ISSIO:iER 1Vorkers' Compensation insurance Atlidavit: Builders/Contractors/Electriclans/Piumbers Annlicant Information Please Print Legibly V 111nC(Uuriness,OrsaniratioNlndividuui):�� nI FI'�ird� Ce nls'�T (D )✓! Address: geee4 S r City/State/Zip:g1AA1a�4CA rd r� Phone N: —0 Are you an employer?Check the appropriate boa: Type of project(required): I. tU tarn a employ er with 4. El am a general contractor and L P Y e have hired the sub-contractors b. ❑New construction elatptoyeea(fulland/or art-rims). 7, Remodelin 2.El1 am a sole proprietor or partner- listed on the attached,sheeL I g ,hip and have no employees These subcontractors have a. ❑Demolition working.ter me in an capacity. workers'comp.insurance• 9 Y P IY• ❑Building addition (No workers'comp.insurance 5.'O We are a corporation and its required.) officers have exercised their ME]Electrical repairs or additions 3.C] I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.(No workers'comp. c. 152,§1(4),and we have no 12,C] Roof repairs insurance requited.)t employees.[No workers' 13.❑Other cump.insurance required.). ;Any uppll.am dnt chsks bex ill must store rill uut the ucriue bdowshowing their woakes'compensation polity inrunratton, r If'. . en who sabmii this affidavit indialne they am doing all work and then hire outside contractors must submit a new afttdavil indicating such. :Cunimctors that chsk this box mint unshod an additfurd ehet showing thenamo oftbaauba iuractom and thnhr workers'ramp.policy inrormadon. l um an employer that/s pravldlnx workers'comprrrtsatlon buurance for my employees: Below Is the pollay and fob site infornratlons insurance Company Name:�M.de.) /r•rs / Policy 4 ur Sclf-im.Lic. 0: ts: 6r � e Ott) G/cr7/ �-/ Expiration Date: 17- Ze f ? Job Site Address: City/StatOzip: Attack a copy of the workers'compensation policy declaration page(showing the pollcy 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 S1,300.00 antler one-year imprisonmcnq as well as civil penalties in the torm of a STOP WORK ORDER and a tine of up to 3230.00 a day against the violator. Ue advised that a copy of this statement may be turwardud to the OI'lice of Investigutimrs ui die MA for insurance coverage vcriticalion. Ida hereby certify under that pubes and penalties ofperfury that the hifurarat/ow provided above is true and correct. 9iennurc&— � az� Data: OJJlcial use Only. Ors not write in i1dr army to be cuarpleted by city or town a/jlelal. I City or Town: __„_, Permit/Llccnse.Y _____ I . Issuing Auihority(circlo one): 1. Uourd of Health 2. Uuildint;Department 3.Cityi rown Clerk J. Electrical Irnpector 5. Plumbing Inspector I 6.Other -- ----_ Contact Person: l'hon¢lt:. I , ,- ,: �"")--=,a+,'F^ a&'zs<x+�+..e- , °^^'1e.m.• y'T �v'�x e. y..+�st�" *yak _'.'. 'tp'rYky'x°R'rlTa d � /X JN 0 r Y tap.. _ t Office of Consume, A, airs`Eind Business R6guldtle },, 10 Paik Plaza - Suite 5170 }� { Boston"Massachusetts 02116 I r� 7 Home Improvement Co�tractor Registration - _ a�~-- � �— � Reg,stratton �175146• jr 7,, Typ&rtindividual Expiration'13/21/2015 TrM 238994 =a �C 'GEORGE W. MABEE :GEORGE MABEE 103 ESSEX ST � � SAUGUS, MA01906 w Update Address and rNurn card Mark reason for change , Address Q Rettet al 'Ig Employment Lost Car _ SCA 1 C� 20M-05/,1 - �G i£ "«iW k ,q. •aj :w i _�� ri ... J, License or registration valid for indrvidtiZ,'useonly _ OtTiik of Consumer Affairs&Business RegulationZf �00E IMPROVEMENT CONTRACTOR Type: before the expiration date. found re to: eg;stration 175146 Office of Consumer Affairs and Businessss Regulation 10 Park Plaza-Suite 5170 Expiration 3/21/2'01_5i Individual Boston,MA 02116 GEORGE W.6IABEE� k ,q GEORGE MA6EE 103 ESSEX ST SAUGUS, MA 01906 . _ Undersecretary Not valid without signature 'Board of Buldin Department of Pi plic'Saret'x ., g Regujations and -... Gnfstructi4ti Suncn'isor Standards License CS-061997 m L GEORGE W SEE o 103 ESSEX S:'F`f ..r' s SAUGUS H. o1906' TV G W �t{t IIA a commissioner - Expiration a - 11130/T013-w I i I i I I I COMI'ITq - - '' CITY OF SALEM 1NIASSACHUSETTS ass `rs DEPARTMENT OF PLANNING AND sueo COMMUNITY DEVELOPMENT K[MBERLEYDRmcOLL SA MAYOR 120 WASHINcroN STREET ♦ SAWA,MASSACHUSKM 01970 LYNN GoomN DONCAN,AICP TELE:978-619-5685 ♦ FAX:978-740-0404 DIRE=a HOUSING REHABIUTATION LOAN PROGRAM BID FORM f Property: 13 HAZEL STREET,SALEM,MA Owner: MARILYN HURLEY J f Section Work Item � � rice 13 v' v' 1.0 Roof Replacement 1.2 Demolition S $ Or) el 1.3 Asphalt Roof ,$ 1.4 Skylight Flas ingIs 1.5 Rubber Roof 1.6 Chimney $ v L3 1.7 Fascia Boards Gutters and Downspouts $ l r 2.0 Front Porch Replacement 1\ 2.2 Front Porch Replacement 2.3 Rubber Membrane Roof $ 2.4 Light Fixture $ 2.5 Lattice and Trim $ 2.6 Front Porch Stairs $ -Z 2.7 1 Painting $ /] TOTAL BID S 90 1, the undersigned contractor,have inspected the above listed property and understand the extent and character of the work to be completed as described in the Work Write-Up. The bid includes every item identified in the Work Write-Up by the respective numbers. The bid shall remain in effect for a minimum of thirty(30)business days after the bid opening. I propose to furnish all labor,materia and equipm ecessary/o accomplish all work described in th Work Writ p for the s o mop Dollars ($>. I would b able to start the project on 1 1 f2013 (estimated date). I agree to begin the work within thirty(30)calendar days of the Notice to Proceed and complete the work within sixty (60 calendar days. 1 agree to fu aran all labor and materials for o e(I)year fro the project completion date. ��/ z� 7 � prop �' Company Na pie Phone Number �i a o uthoriz� Date 13 Hazel Street Pave I Hid Form