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6 HILLSIDE AVE - BUILDING INSPECTION t i The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Applied: z /y Building Official(Print Name) Si Date SECTION 1:SITE INFORMATION 1.1GP7;/ ;AVress�yL 1.2 Assessors Map&Parcel Numbers l.l a Iss 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) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water upply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Dycposal System: Public Private❑ Zone: Outside Flood Zgne? Municipal On site disposal system ❑ Check if yesOr SECTION 2: PROPERTY OWNERSHIP' 2.1 gwne/r'of Rencord: / /� / y J // y� /Jen✓!G O /j dG ./'7✓<- Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED W R10(check a I that apply) New Construction❑ Existing Building Owner-Occupied 04 Repairs(s) CVJ Alteration(s) tAddi;ion Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief /Description of Proposed Work - Ex/s i SX�d raOM /`6rfvo C/ /I/Lti/ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ /z 360 Or d 1. Building Permit Fee:$_IRJ2�Indicate how fee is determined: ❑Standard City frown Application Fee 2.Electrical $ 01,0 ©O ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 3000.00 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ / $p J p� 13paid in Full [3 outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /,,/ C',�U, License Number Expiration Date Name of CSL Holder / �o/L e� List CSL Type(see below) V No.and Street A//l U Unrestricted(Buildings �[;/7• 30 y� ildin s u to 35,000 cu.ft. 4 Restricted 1&2 Family Dwelling CiWow XState,ZIP M Masona RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances ��8 �/�3- 6�63 /�/66ao��/•nco�2orOJGnx.�co I Insulation Telephone Email addres's D Demolition 5.2 Registered Home Improvement Contractor(HIC) �o�� ®a�w h /OSoo�io 7 6ti/ HIC Registration Number Expiration Date HIC Compan Name or HIC Registrant Name No.and Street Email address C t,State,ZIP Telephone SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.$ 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 Issuanye of the building permit. Signed Affidavit Attached? Yes ..........& No...........❑ SECTION 7a:OWNER AUTHORIZATION TORE COMPLETED WHEN,, OWNER'S AGENT OR CONTRACTOR APPLIES FOUR 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. C�,uvd`o 9113 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 contained in this applicaf n is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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 M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. o� v/dr s 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 3. "Total Project Square Footage"may be substituted for"Total Project Cost" i CITY OF &U.ENI, NLNSSACHUSETTS • BURnLNG DEPARrtENT 120 WASHINGTON STREET,Yet FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KLNiBERLEY DRISCOLL MAYOR THOMAS ST.PIEftRH DIRECTOR OF PUBLIC PROPERTY/BUILDING COS NOUIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� Please Print Le¢ibiv Name(BusinessD/WnizationAndivid1ual): �� (70�(/-'V0 7 es /Address: / Lti' /tC`0 City/State/Zip: � p`/ Phone Are on an employer?Check the appropriate box: Type of project(required): P J (req �: 4. Q 1 am a contractor and I 1. 1 am a employer with ✓�°mil 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors ,, 2.❑ I am a sole proprietor or partner. listed on the attached sheet t 7. I(G'Kemodeling ship and have no employees These sub-contmctors have ll. Q Demolition working for me in any capacity. workers'comp.insurance. 9, Q Building addition [No workers'comp. insurance 5. Q We are a corporation and its required.] officers have exercised their IO.Q Electrical repairs or additions 3.Q I am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions myself.[No workers'comp. c. 152,§44).and we have no 12.Q Roof repairs insurance required.]t employees.[No workers' comp. insurance requited.] i].❑Other Any applicant that thecae bon#1 must also rill out the Salim below showing their worker'compensation policy infomtadon. Ihmteawrna who submit this affidavit indicating they am doing all work and then hire outside cram seems must submit a mar affidavit indicating suds lConmaoor that check this boa must attached an additional sheet Slowing the name of the subcvntrctom and their wohas•comp.policy infomsdoo. 1 am an employer that is providing workers'emspensadon lasaranae for my employees. Below is the pollry andjob site information. Insurance Company Na Policy �y/✓�+ / ,�./ Policy#or Self--ins./•Lich.#: 60/S/n7S0/ Expiration Date: f///Xi Job Site Address:b Jc �Ile- City/State/Zip: .S /,_,, 1 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Inwsligatiuns urthe DIA for insurance coverage verification. 1 do hereby cerdA under the pains and penaties of perjury that the information provided above is true and correct. Signature, i� - Date, Phone# rrY6.3 OJf7ciel use a+1y: Do not write in this area,to be completed by city or town 091c1aL City or Town: Permit(License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person• Phone#• CITY OF S��I.E:�I, �I.�SS�ICHUSETTS • BL'ILDIING DEPkRTJtENT r 130 WASHINGTON STREET, 320 FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KINIBERT FY DRISCOLL MAYOR THOMAS ST.PMM DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%IISSIONER 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 willbe transported by:// (name of hauler) The debris will be disposed offiin : s ol� 1305/py (name of facility) //o S1 //;�'. (address of facility) signature of permit applicant date dcbria ffdm r Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen isor License. CS-061670 MICHAEL F GOO�WIN '- 7 HOLT RD = x f Epping NH 031111f ;j. ~: n-W`s Expiration Commissioner 08/08/2015 fV/re`oPooxn<rY,rroeaD/r,offC%l�r�ac/r.�etG License or registration valid for indrvtdul use'onl Office of Consumer Affairs&Busihess Regulation Y 9,9 OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistrahon 105029 Type: Office of Consumer Affairs and Business Regulation xpiration 711612014. Individual 10 Park Plaza-Suite 5170 i Boston,MA 02116 MICHAEL F.GOODWIN JR .Michael Goodwin Jr. -EPPING,NH 03042 - � - Undersecretary � Not valid without signature