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17 HIGH ST - BUILDING INSPECTION .. Jb �Ul/ — —— ---- The C'ununonweallh of Massachusetts UNNI 1; i� Board of Building Regulations and Standards CITY OF j Massachusetts State Building Code. 780 CMR SALLM Building Permit Application To Construct. Repair. Renovate Or Demolish a One-or Tuu-Fanoilr Du elhoki, This Section For Official nl Building Permit Number. Date A plied: UwlJing 011icial(Print N:une) Signature J 1' )ate / SECTION 1: SITE INFORh1aT1ON 1.1 Property Aress: 1.2 assessors Alap& Parcel Numbers 12 d I.la Is this an tccepted street?yes no Map Number Parcel Numtter 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed the Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(It) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? C Check if cs❑ Municipal ❑ On site disposal s)stem ❑ ION2: PROPERTY OWNERSHIP' 2.11,J111P r o Record- ttQ�1f Nan Prin�� rt r Sw SCo {'a- iMeA NO.and Strcet Telephone Email Address SECTION J: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ .accessory Bldg.❑ NumberofUnits_ Other ❑ .Specify: Brief Description of Proposed \Vork': Rep � ee r SECTIO 4: ESTIMATED CONSTRUCTION COSTS item Estimated Costs: (Labor and ..\laterials) OfTicial Use Only I. Building $ I. Building Permit Fee: S Indicate how fee is determined: '. Electrical $ ❑Standard City?o,vn Application Fee ❑Total Project Cost'(Item 6).e muitipiier x t. Plumbing S 2. Other Fees: S ----� 4. .Meclt:1tica1 IIf\':\('1 S List: r — \Icchanical (Fire Su t tn:iiionl S Total .\II Fees: $_ ---_- �! v. Total Project Cust: S Check No. __('heck :\mount: Cash \urounc - - - �7 — ❑Paid in Full p putst;mding Balance Due; aJ i�6C���r� SEC'1'10N 5: ('ONSTRIl C1'ION SERVICES 5.1 Coast acion Su )ervisor License(C'SL) 13 In , coop--- --- - 1(1, �� t— Lianx Numher pep ratio D;oe N;une of C'SI. I luldcr _ — --- V List CS I. I)PC Isce hclowl_ -f-1-�-�LN--S-C— -----'---- IN PC Description No. :utd Street 11 Itnrcicted 1I2FWin)s ti cl 15,UIlU at. It R Restricted I&? pumil Dttcllin C'itei fort n,State.ZIP _ M Ma;nn RC Roofin Coeerin AS Window arid Siding 9 / IO�Ca>hcGs tiF .Solid Fucl Burning Appliances J6l)IMF © I Insulation 'felt hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) _ HIC Registration Number lispirutiun Uate IIIC'C'umpany N;une or I IIC Registrant Name No. and Stract 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...........Cl 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: 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. Ko l� Maresca. L d 27 1 Print( wncr'sor:\uthonzcd,\gent's Nmne l E.lectrunic.Signature) Date NOTES: I. An Owner who obtains a building permit to do his,her own work,or in owner who hires in unregistered contractor (tot registered in the Hume Improvement Contractor(HIC) Program),will no have access to the arbitration program or guaranty fund under M.G.L. c. 1 q2A.Other important information on the HIC Program can be found at tttttt n�.r.. t% ;,t.i Information on the Construction Supervisor License can be found at tt\ttt.ni.ts<�,o\ ,Ip, 2 \\'hen substantial work is planned,pro%t, the information below: Total floor area(sq. R ) _ __(including garage, finished basement a(lics,decks or porch) Gross)icing urea I sq. It) __-- _ -_-- __-- - -- Habitable room count Number of fireplaces.---- _ _ _ _ _-- Number of bedrooms Number ol'bathrooms _ _ . . _ .Number of half haths - I\pc of heating system _ . _. ._ Numhcr ol'Jccks, porches I\pe of coaling ;}steal _ _ _ - Enclosed 1. "l\ tal Projeet Square Footage-ma\ he substituted fur"Total Project Cost- too CITY OF SALENI .// PUBLIC PROPRERTY t� DEPARTMENT C I Y',r11N ,,I \I%1,•e il:itlP• i,111•N, M.1 U.h1.111 ,r I ,oo I'c,. D�;1yK'IS a I'1.r v7N•71G'I.rrA Workers' Compensation Infuruned �ll7dubit: ltullderVCuntractur3/clei:trlclunyplumbers � ) IRcun In nrinullo int Le 'AI VdlnQllt114,1e,y1)/cant NII11NInJt Y,llYytl; Cily,Sralt.%ipphlPf �J M G CJr (rhunart; I .\ry y yo un v,nployer.,Cheek Iht:y/proprlart boil: I.(] I:un J cmpluyur wilh o. I am a Junural cuntraetor and 1 1 yM of pro)fat(rwllllred): cla LinpOlf. uyeus( huvy hirad Iho.vuh-eumrw 6' ❑New cunstructiuA lulu prnprienrr ar gannet- lipcd on rht Jnuehed,heist )W havu no mn lu cos �• ❑ng tier mu 1n y capuuity. rs workn bonp,�nyurfcavea• ❑�tmoliriun orkun'cutup, iosuraoct ❑ We are t crnporttinn and its Q• ❑Uuilding addition J.Jatlleen havt cwreisvd IhcirhomeoJulng JII work iyhrofu.rent Lion IO.Q Elacrrieol repfin or udditionf 1N,o wnrkurs'compC.li 1 t fii♦1(t),Pnd wtuhrrvt n11.0plumbing repairs ur additions cu rcyuired.l r .mpluyeus. 1�'o workers' 12-r0a�Ruul•n crimp, insurancu n:yuircd.J 13, allltr 1rs S•.1'q.,,phcue,hle:1!rcYl bossll mun.Jw 011 my lM wenay t"im, Wrury lh„jr rwlurl numlltmWilun iv 'I lum,n,wrrn wily valmN,Aie elTeswilt,Wlutin 1 f,M,rwbyr Ihs11 M.vt this bet mttM Juanwl.Ie WJrury�Juu f JI wort e,t1 IMrr Afro tlwvies rutrtlt 1 y Inrortrtyi,tt► tl,ral Burin f Ih„netts M1As, rtb mar.ulomt s nw.mJevil inllivymf ww,b. /urrr un rnrplayar rhyr lr pryrlJ/nr lvurRert'rurn0enmtlon Lr.runrnaa/ua nrai n rM,bsy turiwt'tany.r.rlmy,erMmosti a in/unnwArti p/J aa.R Bi/urr/f thtpu//ay un0/u1 giro Imurance Company.Vnmtr . Policy /1 ur SalGins. Lic.Its: - i - -'�_._ Eepiraoon Darr. lob Situlddrati.r: illurg a euyy of Ih• workan' rumpenrailnn pulley Juularatlun pugs(bhowl Ml the Polleynumbu►and arpl►aNu■ date). I Jlluru lu mcurt rut eruyt as required uudor.Sccliun'Jr1 ul'.\IGL c. I JJ eau lead ro the iro fins up nr it halts JnJ/ur uu6yeJr rtnpri.rluu^un4 ur well pusitian ofcrltninal penalties of a ,;i tilt io i?!f)Qtl a J.Iy I furnvt the viO1.nar Ile advised Ihut J �wpyl)rfhlhl,llej�c n ntlmuy be ST(JP tha ORDER tlied ui' I'I� All�Jlp,lll wt ,flu MA :gtnnurJrce:uvcrJ�u 1aIlia Jhun. oR1C URGER and tint /,lu/rrrrAy I ani/1•nrrll•'r this nin turd prvnrhier u/yn�nry h d�a in/bnnyNon yru w'da�u Y p: ry e i true ru4/¢orrtY6 rl//Iriu/me un/y, /)u not a sire in this art•u, to.ye twuylelrl/by airy of town n/II,iuL (lrr ur I'norts: k%uin —� PannirtLlcvma f y .lu,hnri,ylcirdennel; I It1,.,rJ „f IIY.ilrl1 !. IludJuy 1),hvr Ihp.utnlanl I. Li I).'to'ro C'Icrk J. l'4•vttiaJl Inspc G. atur :, Pli,mbiny lu,ytclar —' I'hune 1 : information and Instructions �Lus.tchu,au t„icnaral Laws chapter 1 i2 Icywres all euytlo`c+an m iha�se%'Ue of anudurcniuler uty cuntr:tct f hire.v. ow,uant to out ,latuta, an empltss'ee 1s dctineJ as.• every p' . :.Prays or unplluj, Ural or written." oraUun ur other legal cnriry,or any two or snore �n ,•,npluyar is JctincJ as"an inJtvidual, purtnanhip..tssuctauoo,eery ea. However the nsa, and utcludin the legal represeuta"vca of a deceased employes or i t wNenterp a vnnt employlnaentPloy �t iha 1;Ireyuml{engaged �n a) . ecetver the or tru>,tee of .n I,IdivtJual, Pa racrsh,p,assoetattoo or other leg' Y, house hsvina not snore than three apartments and who rasiJa therms or the occupant of uwntr of 1 dwelling of sttch employment be decmeJ to be an ampWyer.' .hvvlluty huu;e o dwelling house who employs persons to do maintenance,cun,uuction or repair work an such)walling uuse ,,r on the vroundt or building appurtenant thereto shall not because $hall withhold the Issuance or \IvL chapter 132. t13C(6) also staoas that"Ovary stsu ar Idea'llctnslas aµtuey Uanes with the Insurance coverage required: renesval life license ur pernslt to uytrate s huslneu or to eoUtruet buildings In the commuaw+ultY for as produced acre ate A evldtace of cump of its elitical subdivisions shall ;lypllcant wbo has not p , �SC(7).ratty"Neither the conunonwcalds not any P \ddiuunully, \IGL chapter 152. i- �untrad for'he parfomwnw ui public work until aaeptabls evidanct ofewuyliartce with the insurane enter into any ' t of of d li the contracting authority.,* raquiramenu of this chapter have been P' %yyllcsn4 cheekina the boxes that apply to Your silualion and'if tttsation allldavit eotnplettlYhane nutttbet(s)°Iona with their cartiAeute(s)of Pla,t+e 1111 out the workers' cumP es)and p Partnerships(LLP)with no amployca°other than the nacassary, supply lub-contractors) am°�L)LC)oft Limited Liability he" insurance. Limits) Liability Camp workars' compensation insurance. If as LL' reta t o�Industrial membare or purtners, are nut required to carry be submitted to the Dep erttployaes,a policy is required. Be advised that this affidavit Insy ni;requested,na#the artl-tant of \ccidenu for cantlrntsnion of inattranco covareae. Also be sure to slap and Jule the ul'ildnvl4 71u otfltlavit shoo ha rctttnsad to the city ei tows thatnsQ the application for the V°n°s�M law or if y out are raqurcd to° l a workers' Industtiul,\ccidanu. Should you Isave any qucenona re umbeg catnpeneation policy, yleeae call the Drpartment at the number listed below. self-insured companies should enter their s s clr•inurance license number on the a ro 11 line. (pity or-rows Officials Iteto printed legibly. Tile Department bus provided u sP°Lathe app 'bottom i Icase he:urn that the afRduvj i°n the aveiclq :utd p leant ,li the altiJavll t'uf you Ir III) out in the avant the 011lce of tnvrsti arsons has to contact you regarding , I'I:usa i sure it. fill in to 1 Pa need only submit ona ifeldavit indicating cuseur nnit/liunse nwnber which will M uaad,��a rifercncc nutnAar. In addition,an applicant ill'moat submit tile in ie yannitllicmtae applications in any given yette't`ast shauW write"all lucutiuns in (' Y and unJar"lob Sits Address'the app be rovidad to the policy inl'mmalkin(if necessary) cd or marked by the city or town Inay P town), ,\ wpY,,f the affidavit that has been officially sump applicant as proof that a valid aiflduvit is on rite for jco t P r Vgri or lot related t saw a urines must m Iofci nut sac Ill,license or pennU not relate)to any business or comatareial vamure ersan is NOT rc4uitcd to complete this alfidavit. y cur. Whert a hums uwnar or cusses is obtaining I i c. a duel license or permil to burn larva ate.) tail P y wsuons. \lvuI I1e 'tldu nut hasuaut to it": us l all+ w Uiwtk you in aJv:uua for your cauperation and should you have.n 4 ca,e fhe U.p.uunant's addrare, {deplane and far nimbler CAuSetU The Commonwealth of Maus Dep Ote o LMJUSLrial Accidents f} Gf IaveadQadons 600 Washington Street Boston, MA 02111 fel. 4 617.727-900 ext 617 10I at 1.877•MASSAFE Fax 4 CITY OF S.1L&Nf, Akss:kcffusETI"S BCttDLVC DEP.1RTlE\T 120 W-kSHLNGTONSTREHT, }ieFLOOR KIMBF_RF Ry ORLSCOLL FAX(978) 7-1&984d .tiUYOIt DiO-%W ST.PmX" DIRECTOR OP PLSLIC PROPEATY/at:MDLYG CONNISSIONER 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 11.5 Debris, and the provisions of MGL a 40, S 54; 11 Building permit p is issued with the condition that the debris resulting from work shall be disposed of in a properly 1 1 1, S 1 SOA. licensed waste disposal facility as defined by NIGL c The debris will be transported by: (name at'hauler) The debris will be disposed of in : Al Q 4± (nameoY(udity) S 0- (iddress or riviG,y) . uynanue ofp rmrt�pp6c�nt t ' llascachusetts- Department of public Safety Board of Builtfin,.- Rc•�ulat4ios :md Standards Construction Supervisor License: CS 61786 XEITH V MARESCALCHI 53 FROND ST BEVERLY, MA 01915 <1mmisaioner Expiration: 4110/2013 Tr#: 13674