10 HEMENWAY RD - BUILDING INSPECTION (3) 013
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY SALENI
Massachusetts State BuildingCode,780 CNIR
Revised.Llnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fancily Dwelling
This Section For Otfteial Use Only
Building Permit Number: Date tpplied:
Building Official(Print Mane). � � Signature-- ' _ Date
SECTION 1:SITE INFOWNIATION
L1 Property Address: 1.2 Assessors Nlap&Parcel Numbers
1.1 a Is this an accepted s reet?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
t J„
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
r 01176
e(Print) C,State,ZIP
f() I�ynamrYyrxr(¢ 72� FS�S
No.mtJ Str ct / Telephone Email Address -
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ 1 Existing Building❑ 1 Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify:
Brief Description of Proposed Work':
�wo A x:i rl am 545ot
6IAcY9y �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building 5 Z - . 6(1 1. Building Permit Fee:S Indicate how fee is determined:
Electrical S ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. 61cchanical (I-IVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: 3
Check No._Check Amount: Cash Amount_
6. Tutal Project Cost: .'S Cl Paid in Full ❑Outstanding Balance Due:
r
SECTION5: CONSTRUCTION SERVICES
a
5.1 Construction Supervisor License(CSL)
� �/� l J
�-"" , License Number ExpirationfDafe
Name of CSL Mulder
List CSL Type(see below)
No.and Street 'fy e Description -
6 Unrestricted(Buildings tip to 35,000 cu. 11:.)
'7� ,255E" !h-4 cl /.r R Restricted 1&2 Family Dwelling
Cityn—own,State,ZIP M Nlasomy
RC Roofing Covering
WS Window and Siding
S I Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Rc is red Home Improvement Contractor(HIC)
cv� 'a✓�""" ,/ HIC Registration Number Expiration Date
1IIC Cum any Name dr HIC Regi ant Name
Nu.a td Street Email address
City/Town, State,ZIP 'rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.,15Z.g 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 Issuanc of the building permit.
Signed Affidavit Attached? Yes ........., V No...........❑
SECTION,7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT'
1, as Owner of the subject property,hereby authorize
t9 act on mty,behalf, in all matters relative to work authorized by this building permit application.
tii'V7_3 1 JJ?
Prid t Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED 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.
Prin 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 not have access to the arbitration
program or guaranty fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
www.maSS.uov'oca Information on the Construction Supervisor License can be found at cv�rtv.n:asanovklM
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
1. "Total Project Square Footage"may be Substituted for"total Project Cost"
J� CITY OF S�U..E,,I, %LAss.kcHusETTS
BUIMNG DEPARTJtENT
130 WASHNGTON STREET, 3ii0 FLOOR
TEL (978) 745-9595
` FLX(978) 7404844
KI\IBF.R1 Y DRISCOLL
NLAYOR ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDNG 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 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:
y�
(name of auler)
The debris will be disposed of in
(name of facility)
---(address of facility)
I
signature of permit applicant
date
CITY OF SiuEm, NLNSSACHUSETTS
' Bull-DING DEPARTMENT
4 r r 120 WASHINGTON STREET, 3*`FLOOR
TEL (978) 745-9595
FAx(978) 7.10-9946
Kl\fBERLEY DRISCOLL
2AAtYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUA.DDJG CO\L\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Nttine(13usintssorganizatiom'Indivi(Iual):
T
Address: ! 9!aAD
City/Statelzip: 'tC�� _/�i fQ CJICL Phone #: 5'?b G/Q 9- YL1 r7 /
Are you an.employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
_ nployees(full and/or part-time).° have hired the sub-contractors
2 I am a sole proprietor or partner- listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees These sub-contractors have 6. ❑ Demolition
working for me in any capacity. workers' comp, insurance. 9, ❑ Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.)
officers have exercised their t0.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I l,❑ Plumbing repairs or additions
myself. (No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.)1 employees.[No workers' I3.❑ Other
comp.insurance required.]
-Any upplicuni nut chucks bur NI must also fill out the section below showing their workens'compensatiun policy i11romation.
'I lomeuwnc x who,ubmit this affidavit indicating they am doing all work and then hire outside contractors mmt suhmil a new affidavit indicting such.
:C.mtr,vuurs[hut chuck this box must attached an addiiiuma sheet showing the name of the subaontmctors and their workers'comp,policy infwmmion.
l um an eutpluyer ihat is providing workers'c'ontpettsatlan insurance for my employees. Below Is the policy and Job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. d: Expiration Date:
Job Site Address: Zb's(�4 r e City/State/Zip:,;- � oF,Zy
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Fuilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. He advised that a copy of this statement may be forwarded to the Office of
Invcstigwinns ol'tbe DIA for insurance coverage verification..
I do hereby certify under in• n enalties of perjury that the information provided ab'oovvee is true and correct.
Sienalure'- �y�'/ L� �/� Data:
Phone,i: /G�V �/ �M/
Official our only. Do not write in Ibis area,to be campletad by city or lawn o iciait
City or Town: _-.__.... ..—_ Permit/License#
Issuing Authority (circle uric):
1. Board of Ilealth 2. Building Department 3.Cilylrnwn Clerk 4. Flectrical Inspector 5. Plumbing Inspector
6.Other
Contact Peron: ..,,_ Phone#:
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