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20A HAZEL ST - BUILDING INSPECTION The Commonwealth of Massachusetts o - Board of Building Regulations and Standards CITY OF � Massachusetts State Building Code, SALEM h Bildi Cd 780 CNIR Revised iLfar 2011 Building Permit Application To Construct, Repair, Renovate Or Demol', -a" One-or Two-Family Divelling ) this Section For Offlicialjfse Only Building Permit Number: Building Official(Print Ndme)j .. Stgn are- Dates SECTION I: SITE IN t IATION Pr operty Address- r�e j � 1.2 Assessors iVtap Sc Parcel Numbers ccepted street? yes_ no Map Number Parcel Number ormation: l.4 Property Dimensions: Proposed Use Lot Area(sq ft) Frontage(ft) tbacks(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 ❑ SECTION2:, PROPERTY OWNERSHIP;' ', 2.1 Oyrltert of Record Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WOR10(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupted ❑ Repairs(s) ❑ 4lteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed ork2 Gf�U G e- SECTION 4: ESTEVIATED CONSTRUCTION COSTS- Item Estimated Costs: Official Use Onl Labor and Lklaterials y` 1. Building $ 1. Building Permit Fee S Indicate how fee is determined: ❑ Standard City/fo%vn Application Fee 2. Electrical ) 3 ❑'Cotal Project Cost ,(Itein.b)xmultiplier x � 3. Plumbing S 2. tither Fees:'S 4, Mechanical (I'IVAQ S List: . . 5. Mechanical (Fire 5 Sii cession) Total All Fees: S_ a,. Check No. Check Auwtint: Cash Amount: I'utal Project Cost: 5 S�Q ❑ Paid in Fnll ❑ Outstandim, Bulancc Dua: r � SECTION 5: crnYSTRUCrION SERVICES .1 Construction Supervisor License (CSL) /C,[ License Number E.rpiratimt Uatc / Name ofName -I- . � �� List CSL Type(see below) No. and Street 'type Description A /G U Unrestricted g Buildin s u to 35,000 cu. It. U O R Restricted 1&2 FamilyDwellin City rown, State, ZIP DI D�lasonr RC I Roofing Coverin WS I Window and Siding SF Solid Fuel Burning Appliances I Insulation Nle hone Email address D Demolition 5.2 Registereo Home Improvement�ntractor(HIC) ��(�� i! l/" �� HIC Registration NNumberspu'ation Uate I TIC Company Name or Ii1C istraut Name No. and Street 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 WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property, hereby authorize to act on my behalf, in all [natters relative to work authorized by this building permit application. 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 a orate to the best of my knowledge and understanding. 7- I'ri t Owner's or Authurircd:\ •ntb Nano Mectrunic Signature) Date NOTES: I. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Houle Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under D.G.L. c. 142A. Other important information on the FIIC Program can be found at www.mass.suv bra Information on the Construction Supervisor License can be found at}vww.rnass.�ovrdL 2. When substantial work is planned, provide the information below: 'Total floor area(sq. ft.) __— _(including garage, Finished basement/attics, decks or porch) (.frus; living area (Sq. f.) _ _ Habitable room count Number of tit op.tccs_.---- Numberofbedrooms --------___ -- Number ut bathrooms `lumber of halEbaths _ — -- I vpe of heating system -,__- --- -----___-- dumber of fleck;/porches _-----___ -- fvpeof coolingsystau _ Enclosed _ --- —_Upon ---- l. I',+tal I'nijea lyuura I:not:tqc may be sub;hhitrd foi Project l'u,[ ' ° CITY OF S,1Lovflg NL-kS&fl CHL'SETI'S s BUILDING DEPARTMENT 120 WASHINGTON STREET, 3-FLOOR TEL (918) 745-9595 FA_X(978) 140-9844 IV.%(BFRr FY DIUSCOLl 'IH �UYOR oF1As ST.P[FxR13 DIRECTOR OF PUBLIC PROPERTY/BUMMING CO\L%IISSIONER Workers' Compensation Insuranc Affidavit: BuilderKantractors/Electricians/Plumbers Anolicant Information �s � fli/ Please Print Leelbly Nance IBusiiwsS Orsanizationflndividual): Addre,g: .3 -.5— City/State/Zip: �e Gf/l 1/t4*— Phone N: / S �{ Are you an employer?Cheek t e appropriate bars Type of project(required): I�m a employer with 4. ❑ I am a general contractor and 1 6. ❑Now construction employees(fwl and/or p -time).• have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached.sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have V. ❑Demolition working for me in any capacity, workers'comp.Insurance. 9, 0 Building addition (No workers'comp.insurance 5. ❑ We are a corporation and its rcyulrcJ.) officers have exercised their 10.❑Electrical repairs or additions J.❑ 1 ran a homeowner doing all work right of exemption per MOIL I I.(]Plumbing repairs or additions myself.(No workers'cump. c. 152,§1(4),and we have no 12.0 Roof rupaira insurance required.)t employees.(No workers' lJ.❑Other comp.insurance required.] 'Any appllcam oast ahcul t bass e1 must also fill uut tho sveliw below showing little wurkan'compensation policy infunnullom 'I horn nawnaso who submit this affidavit indicating thcy an doing all work and than hire cvtsidecomrectors mass.nhsnis a new,alydavis indicating such :C,mi mtun thus aheak this box mass aoechod an mWifonal ohms showing the nano ofrho nbeonbutan and thotr torsion'camp,policy infarmadoa. l ran an employer that ie provilding ivorkrrsa compensation Alsuranee for my employers: Below is the polley and Jab site inra / insurance nre Company Name: (/(� Policy tl or Self--its. Lic. H: I in O I Expiration Dote: Job Site Address: Q CitylStatrJ2ip: 56C7 f/2 Altaeh a copy of the workers'compematloo policy declaration page(showing the policy number sad expiration data). Failure to secure coverage as required under Section 25A of&fGL c. 152 can lead to the imposition of criminal penalties of a line up to S 1,500.00 and/or one-year imprisonment,as well as civil panalties in the(arm of a STOP WORK ORDER and a fine of up to$230.00 a duy against the violator. Ile advised that a copy of this slatcmcnl may be rorwurded to the Ottiea of Inves6galiuts ol'dte MA fur insurance coverage verification. l du hereby crrrlfy under thr pulps andd pdouldes ofperry/a/J,�ya that the lufurnrudmt provided above is true Gird cornet, si,ralu to phone,�: ' Olft ial use oaty. Oa nut write in rids urea,to be completed by city or lawn alliclud City or'rusvn: __ __ Permiul.lcente All Issuing Aulhurily(circle one): 1. Iloard of Ile9Ilh Z. Building flepartinwil I.Cltyffolvo Clerk 4. rfeetrical fnspector 5. Plumbing Inspector 6.Otfur .. __.___...._ Contact Person:. ._ ._. Phano It: n t r CITY OF Sit am) L LSSACHUSETCS ©UILDNGDEPARTNMNT 120 WASHCYGTON STREET, V FLOOR TFL (978) 745-9595 K!MBERLEY DRISCOLL F.ALX(978) 749346 k L.%YOR T'HO.%W ST.PiERRs DIRECTOR OF PUBLIC PROPERTY/BUILDLIIG COSLMISSIONER 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 l l 1.5 Debris, and the provisions of tMGL 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 wi II be transported by: (11anle of hauler) The debris will be disposed of in (name of facility) (address o r fac i l i ty) - signarure of permit ap icant r date i 3wfdriq Qll, CS-091242 PETER NG ETH 3SRUTH AVE DRACUT MA O1926 <" s 0510512014 r� T:lrr�.au ��i t�n rice u( Onmm r t -�' ( u . r n nn ( '"•�s a ;,.HOME W ROV°M •., .. DF,A 1,R�gistration 2947,.1 TfPe: �'�. -t. Expim,tion: 9(c.201:' - {. c'TFi:.I A3E7�1 i;flicuL MA0 02e, l'ndersecreta:T t