15 HAZEL ST - BUILDING INSPECTION 1
The Commonwealth of Massachusetts
°o?d Board of Building Regulations and Standards CITY OF
4� Massachusetts State Building Code, 780 CMR SALEM
1d1 011
Building Permit Application To Construct,Repair,Renovate Or DemoliffiP CTIONAL SERVI ES
One-or Two-Family Dwelling
This Section For Official Use Only 5 .
Building Permit Number: Date Appfied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
L la Is this an accepted street?yes 1 '_ 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:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofatecord: VOA
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 ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other fecify: �cS1'7t f-
Brief Description of Proposed Work:
cl1W ✓_n 2 / rllo/� •'Y eP is'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ Szp 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 $
Suppression) Total All Fees:$
Check No._Check Amount: Cash Amount:
6.Total Project Cost: $ 7'1�Ct7 ❑paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�ot �v� Gll omit 4 r License Num er Expuati Date
Name of CSL Holder
List CSL Type(see below) 41
1/1� ! c�v rl r•C�Q. T
No.and Street �/ t tRRC
OWindow
Description
10 i��tUo r pe1111/] ,. (g� Buildin s u to 35,000 cu.ft.
Cityfrown,State,
Y &2 Family Dwelling
ZIP
verin
WSd Sidin
/� rlInsulation
l Burning Appliances
�x'ri>AS�c( Y/-�Xv."n AVTele hone /Email address n5.2 Registered Home Improvement Contractor(HIC) 3 //l� on Numbber Expiration Date
HIC Compyg,, eor �RegisantName '
fi.tr o-.. 6 C� bO�r,T'IVl'v V�,tOn. A.-G
No.and treet
/y 'o � if email address
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 .......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WREN
OWNER'S AGENT OR CONTRACTOR
,APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize Artcr .,.., �} Z rn q J
to act on my behalf,in all matters relative to work authorized by this building permit application.
eUi2 o
Print Owner's Name(Electronic Signature) Date
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 to the best of my knowledge and understanding.
/h���t� ss at
Print Owner's or Authorized Agent's Name(Electronic Signure) Date
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 can be found at
w-wW.mass.gov/oca/oca Information on the Construction Supervisor License can be found at wwvv.mass.gov/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"
.f
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License. CS-101367
MATTHEW A TH
�:.
5 WILLOW ST
Erf : � NORTH READING .
t r '
Expiration
Commisssionneer' 02115120i6
C�Lie�Ponvnzoouoea a� acfurdella License or registration v id for individul use onl�
Office of Consumer Affairs&Business RegulationIW B Y �}II
OME IMPROVEMENT CONTRACTOR before the expiration dat If found return to: 1
egistration: 1jp834 Type: i*;�XSs-Office of Consumer Affars and Business Regula8on :III
xpimtion: 8/1120:14,: individual _ - 10 Park Plaza-Suite 5170 x" �• -
;,_��,�� --1,-j Boston,MA 02116 ``-`-
MATTHEW A THOMAS
W THOMAS
5 WILLOW
5 WILLOW ST
NO. READING,MA 01884 7 �— -
I. -tJudersecretary Not valid without signature
CITY OF SM EM, %L-+SS.ICHUSETI'S
4 BUILDING DEPARTMEINT
3 r 51 120 \V.\SH4:IGTON STREET, 3w FLOOR
TEL (978) 745-9595
F lrx(978) 740-9846
KI\IBERLF-Y DRISCOLL
"'A-iYOR THoNLks ST.PIE.KM
DIRECTOR OF PUBLIC PROPERTY/13Ca.DCNG CONNISSIONER
1Vorlcers' Compensation. Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print t eeibiv
V;Ime(Husinp+s(7ryaniratioru'Imlividual):Address: �alf/ /�IGvrl'tf //rJir f/nc..s.,c.{ �_y ��•
7 ( \�'�K qn� ?ivt7�
City/State/Zip: Act 002;(/ Phonem q,?°
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 I 6. ❑New construction
iployetes(full and/or pan-lime).• have hired the subcontractors
2 I am a solo proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling
ship and have no employees These subcontractors have 8. 0 Demolition
working for me in any capacity. workers'romp. insurance. 9. ❑ Building addition
(No workeri comp. insurance 5. ❑ We are a corporation mid its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I CI Plumbing repuirs or additions
myself.(No workers' Gump. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) 1 employees. [No workers' 13.0 Other
conip. insurance nequirceij
•Any opplinm nut dwcks box E 1 most also 011 our tho scctiun below showing their woden'eompenaadun policy inlurtnarlun.
'I lomauwn n who submit this atrldiwit indicating they ore doing all work 3n4 then hire outside contractors trial submit a new 31rdavit indicting such
Cmuacwn ihul chick ibis box must anachcxl in addoionol shocl showing the mane of the subrwntneton and their workers'comp,pullcy inlia"atiun.
four un eurplu}'er thuf h pruvidfnK ivorkerr'cunrpturaduu inarrmrca jot my employees lfeluiv Ix Iha pullcy mtJfub site
infirnuutinn.
Insurance Company
Policy 4 or Self-its. Lic. d: 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 secure coverage as required under Section 25A of NIGL c. 152 an lead to the imposition ofcriminal penalties of a
line up to S 1.500.00 and/or one-year imprimnment,US well us civil penalties in(he t'orm of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator lie advised that a copy of this.statement may be f-unvarded to(he 011ice of
Invesrigatiunc idthe MA for insurance coverage verification.
/do hereby c•errify under a pains and pen uulldes of,ver%ury/but the injunnWfun provided ubWis andcornet
Date �
Phoned:
Official use wily. O)not write in this area, to be cwupleted by city ur town n/Jleiut
City or I'uwn: _ _ _ _ Pcrmit/l.icensc t!
Issuing Aaltorily (circle one):
I. Huard of Ileailh 2. ❑uildlnq Departmcut .i.Cily/foivo Clerk d. Electrical Inspector i. Plumbing Inspector
6. Other
Contact Person:.___ ... ___ Phone;r:
�< r.
1� `°.,.� CITY OF SALEM, MASSACEiUSETTS
� BUILDING DEPARTMENT
�\ r'�e �� 120 WASHINGTON STREET,31D FLOOR
�mse�'`� TEL. (978)745-9595
F
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 c40, 5 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:i
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date