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3 HILLSIDE AVE - BUILDING INSPECTION (3) 9-7 G� The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM " Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One or Two Family Dwelling This Section For Offici Use Only31. Building Permit Number, . Date Applied -� Building Official(PnntName) , " Signature SECTION 1: SITE INFORMATION 1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers �Tj� /C , 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) L5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 9 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone Outside Flood Zone? Municipal❑ On site disposal system ❑ ', Public❑ Private❑ Check if yes❑ SECTION'2: PROPERTY,OW,NERSIIIP_ `, 2.1 OWneriofRecor ame(Print) Ciry, State,ZIP TT J 3 lf-Ile-, L -�„�---- Email Address No. and Street Telephone SECTION 3 DESCRIPTION OF,PROPOSED WORK' (check all that'apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ I Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: Brief'Description of Proposed Work': 57 SECTION 4: ESTIIVIATEDCCONSTRUCTION COSTS Estimated Costs: Item Official Use Only " Labor and Materials 1. Building $ �O p 1 Buildmg permtt.Fge $ Indicate how fee s determined: ❑;Standard_City(Cown Apphcatron Fee' 2. Electrical $ ❑Total,Project Cost' (Item 6j x mulhplieY : x 3. Plumbing $ 2.9 Other Fees: $ 4t Mechanical (FIV AC) $ r— List: 5. Mechanical (Fire $ Total All Fees: $ Su ression) ' Check No. Check Amount CashAmotmt: 6, Total Project Cost: $ Q� ❑ paid in Full . 0 Outstanding Balance Due: SFCTION 5: CONSTRUCTION SERVICES i, 7tC.�Ll visorLicense(CSL) License Number Ex irati i Date List CSL Type(see below) - 'Type, - Descriptions- U Unrestricted Bmldm s iin to 35,000 cu. ft. Qty State, Z[ �� Restricted 13Q FamilyDwellin bl Masonr RC Roof, Coverin WS Window and Sid4ep"Itt SF Solid Fuel Burni /CL I Insulation Icle hone Email address D L/Demolition � ,, 5.2 Register d Home I provement Contractor(HIC) — �HIC Registration Nutt I-I n Na e or C Regis vn Name o. a �treet�� 7, /�i�� Email address City/ own, State, ZIP ' yo 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........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT "'IT as Owner of the subject property, hereby authorize_� fG d� to act o my be alf, in all tter lative to work authorized y this building perm' application. Prin wn 's Na ( ectron' ',i ire) Date SECTIOI 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 accurate to the best of my knowledge and understanding. Print 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 Hoene Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fiord tinder M.G.L. c. 142A. Other important information on the HIC Program can be found at www.triass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos 2. When substantial work is planned, provide the information below: Total Floor area(sq. ft.) (including garage, finished basement/aftics, decks or porch) Gross living area(sq. ft.) Flabitable room count Number of fireplaces Number of bedrooms Number of bathroonts Number of half/baths Type of heating system_ Number of decks/porches _ Type of cooling system Enclosed __Open 3 "Total Project Square Footage" may be substituted for"Total Project Cost" CITY OF SM-EM10 \/LA SS.kCHliSETTS • BI:ILD[NG DEPARTMENT 120 WASHQVGTON STREET, 3se FLOOR T EL (978) 745-9595 FAx(978) 740-9846 [C.,fBFRT F.Y DRISCOLL MAYORTtIObtAS ST.FIaRRs DIRECTOR OF PUBLIC PROPERTY/BUILDING CO',L%IISSIONER Workers' Cornpensation insurance Affidavit: Builders/Contractors/Electricfans/Piumbers A r rlicant information I Please Print Le ibt Namc t0usin ysOrganizatiorvindividual Address: q City/State/Zip: Phone Il: !22A _ZV Are you an employer?Check the appropriate box: 'rype of preJeet(required): 1. I am a employer with 4. ❑ 1 am a general contractor and 1 1 6. El Now construction employees(foil and/or part-time)." have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have 9. ❑ 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 10.❑ 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'camp. c. 152, 41(4),and we have no 12.© Roof repairs insurance required.)1 employees.[No workers' 13.0Olhet camp.insurance required.) 'Any appll<am 1hho dutiks box it must also fill out the section blow showing their worker'enmpensadon Donny information. ILvneuwn»who submit this affidavit indicating they am doing all work and then him outside contractor,man mhmit a new affidavit indicating such :Contractor,thug chstk this box most attached an addidunal short showing tho name of the subaontrxton and theb worken'wrap.policy information. l am ton employer that is provldinR workers'cotnpensadaa Luuranee for my employees. Below is the policy and job site h1forrrafion. Insurance Company Name, Policy d or Scif-ins.-LLic. n: I/�/9 Expiration Date: d _ lob Site Address:. I�V[(.CL2 =p City/State/Zip: - Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section25A of MGL c. 152-can lead to the imposition of criminal penalties of a tine up to S 1,500.00 antVor one-year imprisonment,as well as civil penalties in the Corm of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. lie advlsed that a copy of this statement may be forwurdcd to the Office of Investigutions of the DIA For insurance coverage verification. l do hereby c er an err the pal s uud p uI I ajperjury that the hrfarntutlets provided abuv is tru led c orrect Data: Phone J (2))icial use anty, Oa not write in III&urea, robe caaspleted by city or Iowa o/Jlc'laL Cityor'fuwn: Permit/1.1cense4i Issuing Aullarily(circle one): 1. Board of lleulih 2. Building Department 3.Cilyt'fuwn Clerk 4. Electrical inspector 5. Plumbing Inspector 6.Other,—.,. -_----- Cunfact Person: ..., Phone#: i _ CITY OF S.U.E . N'IASSACHUSETB i3uu.DL\G DEPARTMENT N 130 WASHIINGTON STREET, 3° FLOOR TEL (978) 745-9595 FA..c(978) 740-9846 KIJiBERi EY DRISCOLL MAYORTHO�tAs ST.PtERRS. DIRECTOR OF PUBLIC PROPERTY/BUILDNG COJLMISSIONER 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 t 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 111, S 150A. The debris will be'L�t/traansnported by: d�� 4 L , (name of hauler) The debris will �be disposed pof in (name of facility) (address of facility) ignatur of permit plic date Jdni,alt'.dk Office of CoosumerAflairs&B smess RegttSatiou HOME IMPROVEMENT CONTRACTOR Registration-,.,,'I34319 TyE.i � Expiration 10l2k013 DBA r i .JOLY CARPENTERBUILDER MARK JOLY 38 COOLIDEGE RD DANVERS,MA 01923 - _ 6n zr:,c<,i-etary - Massachusetts -Department of public Safety Board of Building Regulations and Standards .Construction Supen kor License: C"5804o MARK R JOLl'- 38 COOLEDGE RD DANVER5 DJA 01923 = . y 41'1` Commissioner CXpiratio^ 01N8/2014