14 HAZEL ST - BUILDING INSPECTION j - 325 I
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
1 Massachusetts State Building Code, 780 CMR, 71h edition MUNICIPALITY
USE Jr
Building Permit Application To Construct, Repair, Renovate Or Demolish a R W JaAry
One- or Two-Family Dwelling 171-r008 0�
This Section For Official Use 01i1y n
Building Permit Number. Date Applied: /-
Signature: - ,.< �4V
Building Commissioner/Inspector of Buildings ' " Date. •�„'
SECTION Ii SITE INFORMATION,
1.1 Properttyy Addrgss: 1.2 Assessors Map& Parcel Numbers
Ze
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: ,
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY,OWNERSHIP
2.1 Owner'of Record:
Name(P ' ) Address for Service: -
Signa ure Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied. Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify:
Brief Description of Proposed Work :
G
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only ,
(Labor and Materials)
1.Building $ 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 $
Su ression) Total All Fees: $
G I Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ L ` 0 Paid in Full 0 Outstanding Balance Due:
F�
SECTION 5: CONSTRUCTION SERVICES p 5.1 Licensed Construction Supervisor(CSL) /(9ZZ / lz F I
S� ck{�wu LI�-` License Number Expir tion Date
Name of SL;Hol r
r„t , e, 1: _,w l Nr'/,N List CSL Type(see below)
Addre " : Type "'.
DescriptionU Unrestricted u to 35,000 Cu.
[.
Signature'' R Restricted 1&2 FamilyDwelling
�J -Z�(,.3f.+ I Mason Onl
C,"* RC Residential Roofing Covering
.Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
.' D Residential Demolition
rt 5.2(Be ister� o m gtggt,CoVnt�rac(pa(HIC) 1114
HIC Co�parib r o F IC Registrant`_ _NamK•! �'lJ Registration umber
Address Expimt' n Da e
Signature /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 ......... No ........... ❑
SECTION 7a:,OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 6i r f 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.
Si attire of Owner Date I
A ;; S,E�CTION 7b:OWNER',OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
t G tA-�-{LcJ
Print N e
Signature o wner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
1. 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 and.
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I I O.R5,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 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"
Work Order
North Shorc Community Action Programs, Inc. Job Number: Aboulmal (1)
119 Rear Foster Street, Building 13 Work Order Date: 6/10/2014
Peabody, MA 01960 Ownership: Renter
Phone 978-511-0767
Mass WcaBicrization Auditor: Brandon Dorrington
3 Occan Avenue - Email: bdorrington(anscap.org
Salem MA 01970 Cell: 781-540-8569
Email: massiN vii::comeast.net Phone: 978-531-0767 X121
Phone: 978-741-3471
Fatiha Aboulmal NGRID Electric $4,499.72
14 Hazel St Total $4,499.72
Salem M.A 01970
617-223-7331
Contact Phone: 617-223-7331
Safety Issue(s): Asbestos on Pipes/Knob&Tube Wiring/Lead Paint Possible
4A' tllii od A (
Measure Description ,�a�; a C, uCommentS
Qty �xp: e ilw+rdL'OTaI n Q:tYa, ' Otl ry' :�f r r '.'- $ r
- Xi'tic insulation
R-38 unrestricted -.settled cellulose 1400 $1.65 $2,310.00 1400 $2,310.00
Cttic Ventilation a -
..
Turbine Vent 1 $188.00 $188.00 1 $188.00
:�MiscMeasures > ? � �� a »�c� praas,
n.,t+A . �,. ..
Attic sealing with two-part foam 2 $84.00 $168.00 2 $168.00
Wall Insulation
Double nailed asbestos/aluminum 708 $2.59 $1,833.72 708 $1,833.72
(dense pack)
Total $4,499.72 $4,499.72
Date: 6/10/2014 Page I
a
Office of Consumer Affairs&Busifiess Regulation
'a'
OME IMPROVEMENT CONTRACTOR
egis
t2tion: 111617 Type:
-.-. . xpiration: 111.2/2015 Private Corporatic
MP.SS wEATHERIZATION,INC
RICHARD LAMBY
3 OCEAN AVE Q _
SALEM, MA 01970 Undersecretary
a
1,91s Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supcn isor SpechdO =
License: CSSL-102293
v
RICHARD LAMBy-
3 OCEAN AVENUE v it
SALEM MA 01970
Expiration s
Commissioner 0 510 3/2 0 1 6
i ne (,ommonweatrn of ivtassacnaseas'
Department of Industrial Accidents
Office ofFnvestigations
i 600 Washing on Street
Boston, l+ 4 02111
xmnv.mass.;ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A. plicartl information Please Print L,eLiFrEv
Nanne MASS WEATHEMZ7ATIDN INS
3 OCEAN AVE
kddress:
City/Statc'Zip
Are you an employer^. Check the appropriate box: 70usn
ect(required):1 l am a en)Ocvcr tr it, 4. ❑ I am a general contractor and Iuctionemployees (full and/or pa t mej.* have bred the sub-contractorslisted on the attached sheet. eling❑ 1 am a sole p:onr!etor or par ner- 7•hese sub-contractors haveship and ha,'e no employees ition
employees and have workers' Building addition
working for m� in any capacity. 9. ❑ g
comp. insurance.:
(No +porkers comp. insurance ME] Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ I am a honuco'+ n r doing all wort: officers have exercised their 11.❑ Plumbing repairs or additions
myself IN( ":(O! cis' comp. right of exemption per MGL 1).❑ Roof repairs
insurance t�cq.tircd.] r c. 152, §1(4),and we have no I3 Other
employees. [No workers'
comp. insurance required.]
'.km apphcanr ihui ci,i hr�:u I most also fill out the section below showing their workers'compensation policy infomtation.
r Homeowners v;ho aiF.tn�', 'nis affidavit indicating they are doing all wort.and then hire outside contactors must submit a newg adavil indicating such.
contractos Ihs!citecl:mr bus must attached an additional sheet showing the name of the sub-contractors and-foie whether or not those entities have
r
emplovees. If the suh-comrnnors have employees•they must provide thew workers'comp.policy number. '
I am an enrp(r„-e;'drat is providing workers'compensation insurance for n�v employees. Below is the policy and job site
information.
Insurance Compa,t:. "game: n }
Policy k or Self-ir.>. !.ic. = J f"i Expiration Date: 1 3 �..�)�//�
Job Site Addr _1_ess-: --, f City/State/Zip:_ ��L.—
Attach a cop} of ibc;corkers' compensation policy declaration page(sbowing the policy number and expiration date).
Failure to secure covci a,c.as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to Sl 5n( U: andlor one.-year imprisonment, as w,eil as civil penalties in the form of a STOP WOF K ORDER and a fine
ur up to S2;p,(!;'I „ ,ji,\ against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the II!:4 for insurance cove,aee verification.
I do hereby eerie; under the pains and penalties ofperjury that the information provided�abbove is rrue and correct.
Sianaturc: -_----._.-\Y Date / �0
-
Phone+. _-i-
[Other
- nnlr. Do not write in this area, to be completed by city or town official
vl: Permit/License#
thtrritc (circle one):
f l-ic.atth 2. Building Department 3. City/Town Clerk 4.Electrical Inspector ;-. Plumbing Inspector
--
crsou:___ Phone#: