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23 HIGH ST - BUILDING INSPECTION (2) 7.od �9 r� The Commonwealth of ivfassachusetts } Board of Building Regulations and Standards CITY OF SALI Massachusetts State Building Code, 730 CMR Rev;er!�Earl2011 Building Permit Application To Construct, Repair, Ren to Or Demo li a One-or Two-Family Divelling l 'this SectionFor Ofcial Us'Onlyl, ! Building Permit Number: [)ate Appiie B tiding Official(Print Name) $iinatnirkl. Date SECTION L SITEINFORiiV I.1 Property Address: 1.2 Assessor ap& Parcel Numbers 1.1a Is this an accepted street?yes V^j no Nlap Number Parcel Number 1.3 Zoning Infor tion: 1.4 Property Dimensions: Zoning District Proposed Use Lot Ares(sq ft) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water upply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage isposal System: Public Private❑' Zone: _ Outside Flood Zone? Check if yes[] Municfp On site disposal system SECTION2, PROP.ERT1l'OWNERStDY '': 2.1 OTwnert of Record• V Off'eA�' � l mw Za A.1 �_ Name(Print) J City,State,ZIP 61 �o leITI, tic t�2<v e 97 yl?536 e s N No.and Street Telephone it Add Ass C 0� SECTION 3: DESCRIPT ON OF PROPOSED.WORJe'6heck I that apply) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ NumberofUnits_ Other ❑ Specify: Brief Description of Proposed Work": ll�eM6l�e/ � .Cr'A/ seo0/rS Z•C//� pe Sleo /ham SECTION 4: ESTINLATED CONSTRUCTION COSTS- ftetn Estimated Costs: Offtclal Use Only: Labor:md Materials 1. Building S 006 6 I. Building Permit Fee:S Indicate how fee is determined: . Electrical g /QO� ❑Standard_.Cityfrown-Application Fee 2 2 Plumbing $ ❑'fotatPiojectCost (ltem.6),cmultiplier x -:�AO 00 2. Other Fees S i. M-ehanicdl (IIVAC) S List: i. ,Mcchanical (Piro in L+ versi—on) 1'utal All Fees: S — L Cliaek No. Check Amount: Cash Aowunt: n I'ntal Project ('oil: $ G p O (J. ❑ 11ud ut Full Cl0uhtandin, IhI.111ce I tuw SECTION 5: cw4s-rituct-ION SERVICES 5,1 Construction Supervisor License(CSL) ! F. GA _ Icense Number E.epiruiun Datc / Name of CSLIlI littler J List CSL Type(ice below) _ a0 `eQld�C Type Description No. and Street Q/ U Unrestricted Duildin s u to )S,000 cu. R. © < b R RaAricted 1 FuF�unil Dwcllin Ciryi town,State,ZlP �( Nlasonr RC Raotin Cuverin WS window and Siding s 764 R/agdi 0A - SF Solid Fuel Burning Appliances Q7� Q�Sl� 7 J J dr•6M I Inwlatiun 1 Email address D Demolition 5.2 hone ` , .Z Registered Home improvement Contractor(HIC /) f�` G A Q HIC Registration Number Expiration Date HIC IC Cuin a Name or IIIC Regie ant Nmne e � f2 /ile— ail a res No.and Street L��l p7�y�S369 7 Ci /Town,Sta 'LIP rele hone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 2SC(6)) Workers Compensation Insurance affidavit must b completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issu a of the building permit. Signed Affidavit Attached? Yes .......... No........::. SECTION 7a: 01YNER AUTHORIZATION TO DE COdIPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, is 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 sF.CTION 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 an 1 curate to the best of my knowledge and understanding. _ mate I'ri O ncr't u utlwrired:\;ent's Name c�trunie Signature) No•rEs: I. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor (nut registered in the [ionic Improvement Contractor(HIC) Program),will rrnt have access to the arbitration program or guaranty land under M.G.L. c. I42A. Other important information on the HIC Program can be found at R\yw IICI.ii.gpyiUea Information on the Construction Supervisor License Can be found at wwly-i llass.^oo tILL' 2. When substantial work is planned,provide the information beluw: _('including garage, finished hasement/m ics,decks or purch) Tut:d tluoruea(i I. It.) tlroi; tiving m'ca(it] It.l .— FL Number ofbed room count Number of tireplacci- .------_— `lumber of liA bedrooms -----____-- ._—._-- Number of bathromns .-,_--_- --- .-- Number of hnl6batlu -.----' f`•I7e of hd.a1111� iyitdill - -- m under o(decki.'rordiei pCll __ ... I\peal c,lnliu� ;y;tenl _____ t lotot,ll Pw), .t S�lu.ot 111.1y ha ad±,titut'd t,a Pnslcct CITY OE SiuYINM, 2ANSSACHUSETTS BL'ILOLNG DEPARTM&NT a ?; 120 WASHavGTON STREET,3" FLOOR TM (978)745-9595 FAX(978) 740-9846 KIJBERLEY DRISCOLL THohtAS ST.PIEm MAYOR DIRECTOR OF PCBLICPROPERTY/BIaIDLNG COSLNQSStONER Workers' Coinpensation Insurance Affidavit: Builders/ContractorgiElectricians/Plumbers applicant Infilrrnatton Please Print Legibly Name(0usinnsygrganixatioro Qlndividual):� Sd�G�Q /� . �t� D/f/ON ( Address: '2!J e c_,z%fir 141 City/State/Zip: om '� phone hl: i Are you an employer?Check the appropriate box: 'type of project(required): I.❑ I am a umployer with 4. ❑ I Un a general contractor and 1 6. ❑New construction ?•loyees(full and/or part-time).• have hired the sub-contractors 2. 1 am a sole proprietor or partner- Iisted on the attached sheet t [�2emodeling pd-pship and have no employees These sub-contractors have 11. ❑ Demolition workingfor me in an capacity. workers'camp.insurance. Y P ry• 9. ❑ Building addition [No workers'comp.insurance S.'❑ We area corporation and its required.) officcn have exerIofsed their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.(No workers'comp. c.,152,.§1(4),and we have no 12.0 Roof repairs- insurance required.)t employees.[No workers' U.❑Other comp.insurance required.) •Any opplle:ml chat chucks btta al moat ahw fill out the secliva below showing thaw workers'mmpenwian paltry inf rmtotfott 'I hwneowmna who submit this affidavit indiwina they ate doing oil work and thea hiio outride cantracttits must submit a new aindavil indicting such. :Conuacton that chwk this box must anwhsd an addifiunal sheet showing the nume of the sub-caninctors and their workers'comp,put icy Infetsnadon. I um an employer that/s providing workers'coinptotratlon insurancejor my employeex Below/s the pollcy and fob site information. Insumnee Company Name: Policy 4 or Self-its. Lie.th Expiration Date- — Job Site Address: CitylStatrlZip: Attach a copy.of the workers'compensation policy dectaratlan page(showing the policy number and expiration date). Failure to sucuru coverage as required under Section 25A o0VIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 undlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that u copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1,16 hereby c e rtfy under the puubt s and per ofperjaty that the inJurmallae pravidrd�b�v/e is true and correct S,. .t /C. Data: Phone t)J trial use only. Du not write in this area,to be cunrpleted by city or town ajj1cl,,t citynr'fuwn: Permit/f.lcense# Issuing Autharity(circle one): 1. Board of Health 2. Duildin(;Department J.Citylfown Clerk 4. Electrical Inspector i. Plumbing Inspector 6.Other ContactNrson: 1'Aoneti: 1 CITY of S,L[ Pf, NL1SSACHU3 � ET Ts 6t:tLD4YG DEP.1RTSlEJiT ,.� 1'0 CV 13HLVGTON STREET, 3 R00 t TF-L (973) 733-9595 i":<lStOELLEY I)RISCOLL FV%(973) 7'14 934,J ,rUYovt 'lxtost�Sr.PtExns DLZECTOR OF Pt:aUC PROPEATY/gt:ILDL`IG CO.LLwSSIO V ER Construction Debris Disposal At't7davit (rcyuirbd for all demolition :utd renovation work) 1n accordance with tits si.rdt edition of the State 13uilding Code, 730 04R section 111.3 Debris, curd the provisions of MOL c 40, S 34; ©wilding Permit y is jssucd with the condition that the dcbrf this work shall be dispused ut'in a properly licensed waste disposal s MOMS from I It, S I50A. fauiliry,as defined by tbIGL c The debris will be transparted by: (uama uChauler) The debris will be dispasad of in (non:er ticdity) ,ipwly •'rrpamirdpplic.mt