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31 HAZEL ST - BUILDING INSPECTION (2) The Commonwealth of tMassachusetts Board of Building Regulations and Standards CITY OF �) Massachusetts State Building Code, 780 CNIR Revised SALE / I Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two-Family Dwelling This Section ForOfficial Use Only Building Permit Number: Date Appl IJ�I[Al�wit S BuildingOfficial(PrintName) Sign e�: 71 Date SECTION 1: SITE INFORiNTATIO 1.1 Property Address: 1.2 Assessors Map creel Numbers AA ZfL S7T 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 upply: (M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes[] SECTION2:, PROPERTY'OWNERSHW' 2.1 Owner'of Record: 10 1f OL—c. SAIU 7?A- Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2'(check all that apply) New Construction Cl Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. Cl Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTINLaTED CONSTRUCTION COSTS Item Estimated Costs: Official Use Onl Labor and L,laterials y` 1. Building $ ! Building Permit Fee: S Indicate how fee is determined: �. Electrical S ❑ Standard City/Town Application Fee ❑Total Project Cost',(Item 6)x multiplier x ' 3. Plumbing S 2. Other Fees: $. J. Mechanical (lIVAC) S List: i. Mechanical (Fire S Sii : ression) Totat All Fees. S G Check No. Check Amount: i Ctsh AlnOirnti 6. Total Project Cost: S ❑ paid in Full ❑ Outstanding Bal;vtec Due: J SECTION5: cowl-RUCTION SERVICES 5.1 Construction Supervisor License (CSL.) License Number Ge uati n Date Name of�or Lis[CSL Type(see below) �� 7'��/Z►'ALA Type Description No. and Street '^ p U Unrestricted Buildin s u to 35,000 cu. tt. �, yr / Restrictedl&2Famil Dwelling City/Town, State, ZIP �- bl iblusonr RC Roofing Cuverai WS Window and Siding �__,_^ SF Solid Fuel Burning Appliances �U�tZA� s �� 1 Insulation "1'ele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1 //��� /u e�T(2_oot C-CM ( -1� - HIC Registration Number .eptr, ion ate 1112 o pany Name or HIC Registrant Name /1 40 No nd Street Email a dress 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 ....:,.... 0 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 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 is true and rate t bes of my knowledge and understanding. r Print Owner's or Authorized Agent's NantcT M ecn' tit Signat rc) 7 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 Houtz Improvement Contractor(H[C) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. I42A. Other important information on the MC Program can be found at www.ntassj ovroca Information on the Construction Supervisor License can be found at wwwmlass.euv.JL [,2When substantial work is planned, provide the information below:a) floor area(sq. Ii.) (including Range, finished basemendattics, decks or porch) ss living are (sq. ft.) Habitable room count mberof tuephlces_ Numberofbedroomsmba-ofbathrooms dumber of halt/bathsu of heating system Number ofdocks/ porchese ofcooling system- _--_-- Enclosed----__-_--Opcil -- �. fatal Project 5qu:uc Footage" may ba substituted tnr"Total Project Cost" T CITY OF SAL.EM2 ti'LASSACHUSETTS ` BUILDING DEPARTNIEINT +_ r• 120 WASHINGTON STREET, 3'a FLOOR TEL (978) 745-9595 F.A.r(978) 740-91144 KI\(BERLEY DRISCOLL THO6tAS ST.PIFxRB MAYOR DIRECTOR OF PUBLIC PROPERTY/9t:IIDNG CONLAtISSIONER Workers' Compensation insurance Affidavit: Builders/Contrac torsi Electricians/Plumbers Applicant information Please Print Legibly Name(0usitxsuOrftni:atiatvindividual):��/ cSTd2a( (AAE/IJ. L0,27- Address: Q9 j2'L) . City/State/Zip:��-�&M.-- ©/9�A) Phone* Are y as employer?Check the appropriate bogs Type of project(required): 1. 1 am a employer with :1-1 4• ❑ I am a goncral contractor and 1 6. ❑Xwos construction employees(full and/or part-Lima)." have hind the subcontractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet I I. &&modeling ship and have no employees These subcontractors have If. ❑Demolition working fur me in any capacity. workers'camp. insurance. 9, ❑Building addition (No workers'comp.insurance 5. ❑ We are a corporation and its !0.❑Electrical repairs or additions required.) officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. (No workers'comp. c. 152, )10),and we have no 12.❑ Roof repairs insurance required.) r employees.LNG workers' 13.0Other camp. insurance required.) •Any applicant that chucks bra[t 1 must also nil out the section below showing their workers'compensation pocky infurmatlott. 'If u.vowmm who submit this of ldavit indicating they am doing all work and than him outside contractor must submit a new amdavit indicating such :Cuntm,fors that check this box matt attached an additional shout showing the name of the sub.contrsaor and their worker'ramp,pulley Information. fain on employer that it pravfdfng workers'compmtsadan insurance for my empluyeea Below Is dis policy and Job sifa, brforrnatlon. Insurance Company Name: 41a1 J[TILe4 S �/7S/rANE r Policy 4 or Scl6ins.Lic. H: M A V — /26 aU Expiration Date' lob Sita Address: 3 / 1111 Z-CL• S City/Statr/2ip: A /iLl.., .044 ,itttach a copy of the workers'compensatlon policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Suction 2JA of NfGL 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 it STOP WORK ORDER and aline of up to SM.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Oflica of Invesiigudom ofthe DIA fur insurance coverage verification. /du Hereby terrify Itet pules r en fries of perJury r/our the Lrfurmutlon provided above is true and correct S'„ . t Daw: Phunc • U/Jfcial use uniy. Do not write in MAY arts,to ber cuerpleted by city ar town n/f elatt I City or'I'usvn: __._ _ YcrmitR.Icenae X Issuiog Aullwrily(cirate sane): 1. hoard of health 2. Building Departtuant 3.Cityirown Clerk 4. Electrical inspectur 5. Phnubinq Inspector 6.Other ----_-- Contact Person: . _ Phone th 1 r CITY OF SOU E1I, NL1S&kcj-jusETTS BUlMC`lG DEPARTMENT 120 WASHNGTON STREET, 3"°Roop TEL (978) 745-9595 RI.K(978) 740-9846 K!\fl3F.RLEY D(tISCOLi. A+LALYOR 7110-% s ST.PIERRa DIRECTOR OF PUBLIC PROPERTY/SUanmG 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, yid the provisions of iv1GL 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: ��oP7hSlt>c �/�T/ltlG (name ofhauler) The debris will be disposed of in (name of facility) _ (address o facility) sire t ermit a licant a yr� date