2 1-2 HOLLY ST - BUILDING INSPECTION fhe C ominunwealdt of Nlassarhusells
V Iloard of Iluilding Regulations and Standards CI"I'1' OF
s1. Massachusetts State Building Cude, 780 CbIR SALEM
I Building Permit Application To Construct. Repair. Renovate Or D u 'sh a
One-or Tlcu-Funlil: Divehi q
This Section Fur OtA651 Use Only
Building Permit Number: 11dale Applied:
Iluilding Official(Print Nmnc) Silpwlurc vDale
SECTION 1: SITE INFORMATION
1.1 rap Z ty Add esa• 1.2 Aaaeswn Riwp di Parcel NumbeNumbersO S(
I.la Is thin an acre ted street? 'es no \lap Nunther 11urc0 Nwnfxr
1.3 Zoning Information: 1.4 Property Dimensions.
Lining District Proposed Uw Lot Area(sq 11) Frontage(II)
1.5 Building Setbaclla(R)
Frunt Yard Side Yards Rear Yard
Required 11ruvidad Required Provided Required Provided
1.6 Water upply:(M.G.1.c.40,154) 1.7 Flood Zone Information: I.!Sewage DI posal System:
Ih,61ic Private❑ Zone: Outside Flood Lyr i? Municipal On site disposal s)stem ❑
Check if es
SECTION2. PROPERTY OWNERSHIP'
2.1 O erlof cord:
osep� SKonnuvsf�( �'S K, MC - 01`i2.3
Name(Print) City,Stale.LIP
f�'yet q�x 3� - 18z3 J siCo nnut.sr r`x6-+tn�-C1 . H�.--
Nu.and Street retephune F.rrtuil Address
SECTION J: DESCRIPT N OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ .Spccily:
Brief Description of Proposed \York': -e➢RtK r�aFj ! wipeAdws rQx ��o>' as S(
a - r,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OM NI Use Only
I L ahur and..\I;nrrials l
I. Building S s� d06 I. Building Permit Fee: f Indicate how fee is determined:
O Standard City:Tusvn Application Fee
'. Iflcarical 5 /J.odD i
❑Total Project CostI hem 6)x multiplier
1 I'lumhing S Ro Udd ?, Other Fees: S
J. m: chaoical ill\ WI S /s _Odd List:.— ----- --'----�Q�-[l�/ \
5u.+rcriionl ro:aru Fces: S
A� Check No. ('heck Amount C.tsh \tnowiu
n Pulal I'rnject Cuvl: S `6Q �fld ❑ P.iid in Full ❑IAustanding Ilal mcc Due:
�GZc.Q r'U �G�l'r`cc KL
SF.CI'ION S: C'ONS'I'RUCTION SFRN'ICFS
S.I ('unstructiun Supers isor License(Ctil•1 3 LG 20 7 3
�Omov kit I Iccnse Nmuhar I ipiraliuu I ,Im
' N.unc ul'CSL I InlJcr
h)q, Iksrripliun '
Nu. and Slreel
yl A �� ���� l I I InrcsUicicJ I I+hulJin t a l0 15,11110 cu. I).)
_��h(J.GVJ )"��._.__�__,. . .__ It ReslricteJ lh_ famil Ihscllin
CiPifoa n,.pane.%II' %I �Maswl
RC' R+wlin Cos Grin
..._. VAS Window'u1J.Sidin
fi ff SF .Solid Fuel Burning %pplianucs
/7 d— 7�}/SYZ3 J S(�o At,i-skt1 2 &jsl,As 1 .Germ. I Insulation
Nlc hull¢ Finail address U Demolition
5.2 Registered Ilume Improvement Contractor(HIC)
IIIC Regis:rutiun Numher liq+irwion Uatc '
IIIC C'ompan) Name ar I IIC Itegirlmnt Nanul
No. and Strue! Finail iddruss
City/Town,State ZIP Tel¢ hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.11 c. 132.1 2SC(6))
Workers Compensation Insurance aMdavit must be completed and submitted with this application. Failure to provide
this atlidavit will result in the denial of the Issuance of the building permit.
Signed AfTldavit 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 U%ww's NWne(Elcuronic Signature) Data
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 informatiun
contained in thi app icasion I true and accurate t the best of my knowledge and understanding.
If L
t 2 5
Prins Usuler'�or:\ nllorircJ.\gent'e Name I I:ectrnlis Sig' ;'I Duce
NOTES:
I. An Owner whu obtains a building permit to do his.her uwn work,ur an owner who hires an unregistered cwrraetur
I not registered in the Hume improvement Cuntrnctur(HIC) Program),will nn have access to the arbitration
program or guirmty fund under M.G.L. c. 141.4. Other inlpurlant information on the HIC Program can be IilunJ at
„+1,1 m.n. ;o% ',.1 Information on the Cunstruction Supervisor License can be found at „m„ n1.1.+ St's .111`
2. \\'hen substantial Isork is planned, pros ide the inl'unnatiun below:
rota) (lour area(sy. 11.1 . __.._1 including garage, lmished basement attics,decks or purchl
Gross lis ing area l sy. 11.1 _-_... — ilabiiable roust eount
\umher of lireplaccs
\unlherofhathrounit _ \umbcrofhalt'halhs .
i I lwol'lwatings)ilcln _ \'unlherufdecktporchcs
i
I\pu Jt �JVling i\Uelil 1 hill+,ud tlpell
"IoLII Pn lieCt titllGlfe 1 Ill;)\ Pc HIbi111111Cd tIV Pr Pj eel t'Plt"
S
C["CY OF S,1LE.Nl. NWSACHUSETTS
1' OLILOING DEPAIUM&NT
l'_O CV.\SHLNGTON STREET, 1'a FLOUR
T EL (978) 745-9595
Rix(978) 7•W-9844
t.<l>tBERt FY DRISCOLL
INLAYO:l TNOILU ST.PIF—ma
DIRECTOR OF PL'OLIC PROPERTY/SUMO AtG C01LLMISSIGNEA
Workers' Compensation Insurance ,%1Tldavit: 0uilders/Contractors/Electrici•ans/Plumbers
4Lolleant Information Plca'le Print Legibly
.MllnC Ilhuitx,�UrOamnlion,Individuail: C)QOS�P,1 /�'�(\ � `L�S�\
Address: l6� �1!/+tJ $T'e—( �•f/-ems
Cityistatc/Zip: �,4,u,; MA— ,honeN: Z
Are you as am player?Check the appropriate box: D6*Y
roject(required):
1.❑ I a a employer with a, ❑ I an a general cumractor and Iconstruction
niplayees(flull and/or part-time).• have hind the sub-contractors
2. 1 am a sale proprietor or partner- listed oil the attached shtet. todeling
.,hip and have no employees These subcontractors have olitionworking fir me in any capacity. workers'comp, insurance.
(No workers'.comp, insurance 5. ❑ We aro a enrporstion anJ ita dmg adJitionreyulrcJ.j OtRcers have exercised their rival rcpsin or additions3.❑ I am a homeowner doing all work right of exemption per MGL tog repairs or additionsmyself. (No workers'clamp. c. 152, §1(J),and we have no f 77insurance reyuired.1 a umpluyees, (No workers' er
comp, insurance required.)
-any arPllawd dW vhatiLa but At mwe also fill law the wutiue bulow showing their wmYen'eampenudun puhut,maumauon,
'I b.muwtave whu.altmit this AirdAvie indieaeing they Ue doing all,writ and then hita""side eallfMcb t mime ruhmit an"anldnvir Indicting ewk:t\,mmulun that check this box mwt aaaahW sn tddfliumd-hse.huwing the nwna a!the rubrunlraoWn mJ their w,,Yen'comp,pulley Infian taeon.
l elm an nnpluyrr thur is pruvldlnX rvorken'cumpensarlan buuranee/ar nay e+npluyrrs. Below far du policy rind fob sire
infartnutlnn.
In.,umncc Company.Name: _
Policy 4 or Salf-inn. Lie. d: EApiration Dote:
lub Site Address: cilyiStateizip:
.\inch a copy of the workers' compensation pulley declaration page(rhowing the policy numbar and expiratloe data).
F.liluru to secure coverage as required undor Section 25A of 1IGL c. 152 can lead to the imposition of criminal penalties of it
tire up to S 1,500.00 antl/ur One-year imprisnnmcnC as well as civil penalties in the form of STOP WORK ORDER and a lino
ar up to S230.00 a Jay against flit violamr. Ile advised that a copy of this.maicmunt may lad iurwurdvd to ilia Oliicd of
Inaesligjtiull.t ol'llw DI.\ for insurance tovcrnga vuriliciliun.
I du hereby rem tddf lhr ✓i+Gua J/+� r l le o/haeriary J+ur the in�unnurlmr pruvideJ lab yr it our +J rdrrret
1 . f /y
—/p Z�j (. �u
U//ic'iu!late Jy, /l.s nnf write in Chia area, to be Completed by,ity ur town.lfrivi
City or-I'mvn: _ . _ I'ermitiLlcenre d
("nine,.\ulhurily (circla one):
I. 110ard of IN111h !. Ilolldln" Ucparlmcnl 1. Cilyi I'otvn Clerk :. F:rcetrlc al bl,pcctor S. Pinmltint4 fill a to
(. 011for
t'nnl.m I'crum:
Phone t:
h
CITY of sm-Ems, AkSS.,CHL:sE-rrs
dt;'Lom; 0Ev.1RTJt8\T
I .0 W-UHNGTON ST1lEg't', 1'4 FLOOR
' I313FRtAYOUWOLL Rkx(973) 110.96.4
MAYOR Mo-%W ST.PMA"
DIaBcrott or pL aL.IC PRovt!aTY/eh•ttoLNQ counnsstoNex
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cade, 180 CMR section 111.J
Debris, and the provisions of MGL c 40, 3 54;
Building Permit a is issued with the condition that the debris resulting from
this work shall be
111, 3 I JOA. disposed of in properly licemed waste disposal raeility as defined by ,41CL c
The debris will be transported by:
New 6-ruG (A„el Sa /I A wAS
(name orhauler)
The debris will be disposed of in :
(name o-tY) '
MAI-
(,dd.rr
Fyn mro uf;ermif ipplic�nr
1JIe