0011 HEMENWAY ROAD- BPA-12-125 a� �11J171
The Commonwealth of Massachusetts -- - - - — --
I Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CM SALEMR /lrt•iseJ.11ur loll
L1JW
Building Permit Application To Construct, Repair, Renovate Or De olish a
One-ur Two-Funnly Dwelling
This Section For gifficial Use Only
Building Permit Number: - ate Applied:
Building OlTicial(Print Name) e lh lute , Date
SECTION I:SITE INFORNIATIA6N
k1.3
1 Property Address: 1.2 Assessors Nlap& Parcel Numbers
!1 a Is this an accepted stet?yes C/noMap Number Parcel Number
Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposals)stem ❑
Checkifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1./,,��/.gQwne l of Recoyd:
Name(Print) City.Siutc,Z P
le", yP�� , � g 4 v � �>o6s_
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ .Accessory Bldg.❑ Number of Units_ Other ❑ Spccily:
Brie script; n of Proposed W rk': ! r/!P
�?s���_� �� ���
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
_. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IlVAC) S List:
Icrhanieal (Fire
tiu'I ression) S 'total All Fees:S 'GO a✓��
Check No. _Check Amount:
G. Total Project Cost: S �O ❑paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) f Q
License Numbf croc —
ispiruti n Datc -
Name ol'C'SI. I lulder
Lis t C5L'f}pe(see below)
_ J �/C—
No.and 3lre• 'Type Ucscription
U I Inresnicted(Buildings uli to 35,000 cu. It.)
R Restricted IK2 Family Dwcllin+
Cityifown.State,Zl P M Mason
ry
6 Rooting Covering
Window and Siding
SF Solid Fuel Burning Appliances
.f 1 Insulation
'Felc hone Email address D Demolition
5.2 egistered IIoo ee Imprro!vernent Contractor(HIC) /+ / ( a
(� V' ICIIC•Registration Numhcr apirut on Uutc
IIIC• ontpany Name or I IIC Registraff Name
No.and Street ¢� y�t*--�,�
Email address
City/Town, State,ZIP 'rele hone
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: OWNE 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
co ed in this application is tr a and accurate to the best of my knowledge and understanding.
AtlZ 0
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do hislher own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor I HIC) Program)•will not have access to the arbitration
program or guaranty fund under.I.G.L. c. 1 4'_A.Other important information on the HIC Program can be found at
s�s�ss.m,p,.gu� nri Information on the Construction Supervisor License can be found at ;ot_dp,
2. when substantial work is planned,provide the information below:
Total floor area(sq. ft.) _(including garage, finished basement'altics,decks or porch)
Gross living area(sq, It.) Habitable room count
`'umber of fireplaces Number of bedrooms
Number of bathrooms Number of half'baths
Ty lie of heating system -- Number of decks porches_
------------ ----- --- -------------
F)peofcoolimgsyslent Enclosed
3. "Total Project Square Footage"may be substituted fitt,,Fond project Cost"
CITY OF SM-E.`I, AsSACHUSETTS
ElLaDLNG DEPARTNONT
I20 W.tiHLVGTON STREET, 3i0 FLOOR
ILL (978) 74S-959S
FAX(978) 740.9846
Kim u.SY ORLSCOLL
MAYOR Moots ST.PrEaa
DIRECTOR OF PLBLIC PROPERTY/at:anLYG co %WISSIONER
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 I 11.5
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
l 11, S 150A.
The debris will be transported by:
l �)��G ✓( Off) //
(name of hauler) �—
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
60
date
�atlll4l�.I•IC
- + CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I Nu:M:1 Y'IMNt VI I
\I w,;st
11C\Lrn,tllTta wt�i18 CL•T• i,tl L•.N, M.1Hn4.111 GF 1 is JI77:
Ild:77fTISti'IS • Pts 97111•7442•9146
1Vorkers' Compensation Insurunce .wwavit: Hui tders/Cuntracturs/Electrlciyns/Plutmbers
► ►Meant In unnution
PI r� tint Le 'bl
V:11T10 I Uuwntc,yt)ra,tnvalinNlnJtvuluull:
lddre.cs: � q9
City,Slam zip. G I'hunr it 7J QG
trot If an vinployar?Check 81 approprlaa box:
I I. 1 ant a cm lea ur with a. I)PM of project(roqusred):
P S ❑ I:ears a gcoural convacwr and!
wnpluyecs(full and/ur putt-tints).• heave hired the suh•cumractors rt' Q Now construction
2.0 I;un u solo prnpricuw or partner• listed on the anachcd sheet % 7. ❑Remodeling
ship and have no cmpluycl.•n Thess sub-contractors have it. Q Demolition
,.Urking tilt me in any capacity, workers' camp, insurance.
I No worltcrs'comp, insurance 3. 0 We are a col 9• ❑ Ouilding addition
rcyuireJ.I corporation and iq
Utttcen have onctcircd their !0.❑Electrical regain or additions
3.Q 1 ant a homeowner doing all work right oratemption per bIQL 11.0 Plumbing repuirs or addition myself. IKo workers'cutup, c. 132.41(i),a we hove no
insurance reyuired.j r unpioyecs. (A;o wotkif 12.0 Ruo1'repuirs
camp insuranwrcyuind.J I3.QUtlier
•n�t>.npheur IhW cAcW burl maa alw Jill um Ihe,ecumt WOW aw,rina'Mr wwktee'cwmtreatvliwt ltuliey uriutltatiat
'I Iutttwtwttrn wka,u6mb this atllrtvit itWlulina they aw Juine all work end Ihq A(m uwcitM eurrnoare mtgl wMttY i nw alnt(tri/ittaiur:na vNk.
•f,MIlnwltMr Ihel cMrY This bum arrahtld.tn 4daiiienMl nllv+rl,Ituwiaa the II3M of die rub.crdraerars and their%wilien'taep.prepay Inrartatritta
/oar an earployrr/but liparaiii Jinx rv°rArn'eutnpenmdon Lrrrnmee/ar lily nnp/eyerr. Brlaiv Is the polity unr//ob.tile
ia�urvnafuin. �`/1
Insuruncu Company Name: CP�o'�i/fL
I'ulicy a or Sclr•ins. Lic.ill;
-- Eapirallon Date: ,�i
Job Situ-\duress; //,a /72Cf K %� ZU
City,SlataZlp:
.touch a copy Of%
% workers,cumpen. on policy cldrallun page(showing that policy number and eaplratlun data).
Pailun w sccura coteruge as required wider Sctliun 231t ul'.%IGL c. 132 eau lead to rha imposition orcriminal penalties of a
tine eat m 50,00 tM antl/ur ui the vi Intpris lic ad t,a.c well as civil pc talhcs in Iho lunn of a STOP WORK ORDER and a fine
Drop to i230.rM a Jay.Itluinst the violator. Ile advi.kd shut a copy urthis smlelnent may be Iurwardcd to the Ullico uC
6lrcan�awnts ul'dw UL1 for nnnrar.ce ancra,u wcrilicauun.
/do hen•by t erti ear v drat paint m prnnhfcy vfperJary/hut the ia/bnrrehon prrvided above is true and cornea
Official nsr only. A0 nor Ivrirr in diir urea, to he completed by city ear fmva u//Iciul
( ity ear I'nwn: _ Ycnnit/Llevme 1/
Loins Aulhorily (circle onc):
I I. IhtarJ of Ilealtb 1. Iluddin� Ocparnncul Cl
I, Cit):'1'unn ark a. Llcctdl Intpcerur :. Plumbing la,yceror
6. Other rie
l'onl./cl I'c nun:
i
Information and Instructions `
Nlassachu.etts lineral Laws chapte I s2 ,eywres all ear every
evion in the ss to ervice of.mother u i tern arty contract Of hire lor their ,
1`ur.uaru to Chia.lalule, an fmprurfe is defined as"..,every p< .
%Press or implied. oral or written." or an two or more
�n crnpfuyrr is defined>s"an individual,partnership,association,corporation li other legal deeatery, Y
�m to «e Nowevcr the
\ the Glre-er 14 engaged m a Iwm en«rpnsa,and including the legal«preseutatives Of a deices eJ employer,or C e
CLC,Ver or traslee ul .art individual, paltnershlp,Assoc Or other legal annry,employing p >'
owner of a dwelling house having not more than three spare ments and who resides Chercin,or the occupant of the
,Iwelling house of another who a urtenant thereto shall uoi house
nbecause of such employment be deemed tuubeaction or reltilif wulk on J neemployer."
or an the grounds or building aDD
\IGL chapter 132. g23C(6)also °mica that"every rise or local Ilcenslg agency shall withhold the Issuance or
ing"or
construct
reasilval Of applicant s0license or permit to operate a has not p ducadacceptable bevsidence ofcumplltrece IN the Core
with the insuranceCoverage loaawtalreg visions
pp icon t o �t as chapter 1 s2, i23C(7)states"Neither the commonwealth not any of its political subdivisions shall
eater into any canlract for the perfomtance of public work until acceptable evidence ul'con e tPlianc with the insurance
have been presented to the contracting authority
«yuiramcnts of this chapter ."
Applicants s that pp t our situation acid,if
Ple, w rill out the workers' compensation affidavit completely.ponechecking
nu i berr(s)the
with their►ertificate(t)of
necessary, supply subcontractors)name(s),eddies°( )' P _ with no
insur-ante. Limited Liability Companies(LLCworLimi Limited
Liability
ab Part
uronce.(lf an)LLC of LLP employees
oes have
er than the
ex are not required to carrycompensation mitt d to the Department of Industrial
members Or parts • ffidavit may be sub
' employe°°.u Policy is required. Be advised that this r ' should
Accidents for confirmation of insurance coverage. Also be sun to sign and date the ursted,not the
vile Department
he reltnmed to tine city or town that the applic for regarding permit
tor low license
r if yuuinue required to obtain tu workers'
of
compensation tion po policy.
Should you have pa questions
compensation policy,please call the peptrrtment at the number listed below. Self-inatued companies should enter their
self.insurance license number on the aPPro riots line.
city or Town Officials
gibly. The
rtment It
Ofvthe Iridry tour you taffidavit
PII outs complete and printed in the event the Office of Investigations as to contact you ran addition,
the
an a provided u sPoest at the l pant
1'I:ass be sure to till in the pamriUlicense numbuios which
in any givenm eclas ear,reed only number.m IatTidavit indicating currrent
That must submit multiple Pennit'licettse slip
y y Y
policy information the necessary)
and under"Job
has been officially stSite amped or markadtb �heuc trvorlowe tmytbe provided to theilans in y or
Y Y
town►."A caPY
id affidavit is on fin for fLtura permits or niceties. A new atTtdavit must be filled nut each
applicant as proof that a Val
e a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
year. Where
l i.e. a dug license a permit to burn leaves ate.)said person-is NOT required to complete this affidavit. uesuous,
I he )tli<c ,ii lnvestigatios would like to drank you in advance fur your cooperation and should you have;urY 4
Meese do nut hesitate to give us a call
Ucp:uoncol's address. telephone and fair number
fhe
The COMMQnWealth of Mis"achusetts
Department of Industrial Accidents
Olflee of Invesdgadons
600 Washington Street
Boston, MA 02111 .
'rel. # 617-727-4900 ext 406 or 1.817-MASSAFE
Fax N 617-727.7749
www.mass.gov/dia
Massachusetts - Department of Public SOON .
Board of Buildim- Re u m lations and Sn(IMAS
' Construction Supervisor Specialty License ,
License: CS SL 100562
Restricted to: RF,WS
DAVID MOORE
3 OAK STREET
SALEM, MA 01970
Expiration: 9/15/2012
('onuuisaimcr Tr#: 100562
:� ✓/re �000isemnueall� o�✓l�av�ac/uaolA .. ._ .
Office of Consumer AReln&Business Regulation
l�� HOME IMPROVEMENT CONTRACTOR
= Registratlon'�. 160617
Expiration _4/12/2012 _ Trill 294008 '
Type
CODA ROOFINGi t j-•,l !
DAVID MOORED = '"•'�` i
3 OAK ST t y g
I SALEM,MA 01970 Undersecretary •�
� r/