24 HORTON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
a Board of Building Regulations and Standards Town of
�V��11 Massachusetts State Building Code, 780 CMR, 71"edition Awmalow
Building Deprt
Building Permit Application To C �Dsveflin
enovaie Or Demolish a
One- o tco-F
is Section For: fficial U e Only
Building Permit Number: a Ap ted:
Signature: �'`'��V .�
Building Commissioner/IfspKtor of Building Date 1
SECTIO SITE INFORMATION
1.1 Pro'p!erty Address: _ 1.2 Assessors Map& Parcel Numbers
TT /SS7/l:J'nN J1
1.Is 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 R) Frontage(R)
rt
lding Setbacks(R)
rom Yard Side Yards Rear Yard
Provided Required Provided Required Provided
pply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
rivate O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
rd:rrfV +dice F2Ercr/ Zy rh2rsNsTint) Address for Service:
�78 L Telephone
SECTION 3: DESCRIPTION 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_ Other ❑ Specify:
Brief Description of Proposed Work': C"+.e. CrAveAlr�
N,�=w
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Omclal Use Only
Labor and Materials
I. Building SOno I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing f 2. Other Fees: S�)�f�
4. .Mechanical (HVAC) S List: /
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
or
SECTION 5: CONSTRUCTION SERVICES p/
5.1 Licensed Construction Supervisor(CJ
J&Z':% o(Z Zd e
T
/O/fN - FL L Number Expiration Date
N.4mc of CSL- Hplder
CS
Type(see below)
Address �, C/'���rt. Description
Unrestricted u to 35,000 Cu. Ft.)
Restricted Ik2 Family Dwelling
Signam e Mason Only
9 V OZ d.� Residential Roofin Covering
Telephone Sidin Residenual Solid Fuel Bumin A liance Installation
Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) /? yO� /16 J`V07)
f7DWf( L_A rO fors ,Lq
HIC Company
N or HIC Registrant Name Registration Number
Nn-s C RY^E G ti[ff
Addrc
Qr 03 C.
fzol�
wisoq pZ�j^ Expiration Date
Si a elephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, yj�T N f /y4a,,.{ 7 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature olTOwn or Authorized Agent - Date /
(Signed under the pains and penalties of perjury)
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 Home Improvement Contractor(HIC)Program),will!&have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned, provide the information below:
Total floors 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 healing system Number of decks/porches
Type of cooling system Enclosed Open
3. 'Total Project Square Footage"may be substituted for 'Total Project Cost"
Boarddof Buildln�nand Stendr�sFr
Construction Supervisor License i.
t.
Lieed§e: C9 66200 �.
Explrat own: 8T2009 Tr# 13027
RestridlOrr
14k -ct' __3
JOHNE
107 HARANTIS LAKE RO
CHESTER.NH 03036 Commissioner
p� �iEe >°iooemm++rieal!/e o�C'aaaacr<eu�
�\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 163407
Expiration: 6/16/2011 Tr# 285498
Type: DBA
HOWELL AND SONS REMODELING
JOHN HOWELL -
107 HARANTIS LAKE RD
CHESTER, NH 03036 Administrator
" CITY OF SALEM
,r PUBLIC PROPRERTY
DEPAR'['MENT
r # Skil \I. \f�•., I . .:I' .
Construction Debris Disposal Affidavit
(rctluired lbr all demolition and rcno atiun work)
In accurdance %%ith the sixth edition of the State Building Code, 780 CMR section I 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 0 is issued with life condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
C.c iro a N A.,•
1 IIJmc of halter)
The debris will be disposed of in : 7.0 VA-Lb b_,Vj- �n
(name Of IJ0IIIV)
IaJdre.. of I�cltitVl
v s
HLIIJ111�ut p:nmt dpphcJnt
IJIr
CITY OF S.U.E.N1, IIaxSSACHi:SETTS
BL'ILDI.NIG DEPARTM&NT
120 WASHINGTON STREET, 3aa FLOOR
TE1_ (978) 745-9595
FAX(971) 740-9846
KIStBFAi Y DRlSCOL1
.V(AYOA Tfion&s ST.PtEM
DIRECTOR OF PLBLIC PROPERTY/HCaDLNG CO%MUSSIONER
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers
A n Meant Information Please Print Legibly
Nalne (dusimc orpni:auon,ln.hvtdual): ' ow.—
Address: 107 ocP
City/State/Zip: G1#-Jrer_ n..if o2 c?o Phone I!: 97Y 8O y o 2>J^
Are you to employer?Cheek the appropriate box: - Type of project(required):
1.❑ I am a employer with 4. 0 I am a gent'ral contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractor �}y
2.IV1 am a sole proprietor it partner- listed on the attached shceL : ? I Remodeling
,hip and have no employees These sub-contractors have S. St_-I� Demolition
workingfor me in an capacity. workrn'comp.insurance.
Y P ty 9. 0 Building addition
(No workers'comp. insurance 5. Cl We are a corporation and its
Ill.❑ Electrical repairs or additions
required.) officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. LNo workers' 13.0 Other
comp. insurance required.)
-Any applicam that checks Boa 01 must also rill out the section,below showing their workm'compertautio t policy infurmatton.
r I hmawnen who submit this aaldevil indicating they an doing all work and then hire outside contractors must suhmit a raw amdavil indicating such,
{„ntrm-en that clack this bon mug attached an additional seat showing der fume order subaomrsctors and their workm'comp,policy information.
/erns an employer that/s providing workers'compensation lnsaronce for my employees. Below/s the policy and fob site
information.
Insurance Company Name: LRk1,r,� t.41,"V,,6e
Policy N or Self-ins. Lic.p: 6 0—7 Y 3 7 LY�i /� CcrA^�r Expiration Date:
Job Site Address: Zt/ 4!J2,1_re, ST City/Statrizip:
,%track a copy of the workers'compensation policy declaration page(showing the policy number and expiration state).
Failure to secure coverage as required under Section 25A of,%IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form Of STOP WORK ORDER and a Erne
of up to S230.00 a day against the violator. Ifs advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby certify u/ndeerr the paaiinns,and pena/riespf perfary that the information provided above is true and correct
Phon it: 2 8 D y Gz> I
iOfcial use dilly. Do not write in this area, to be completed by city or town dfficiaf
City or Tuwn: ecrmit/Llccme q__
hsuing Authurity (circle une)t
I. Board of Ileal,h 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inipeetor
6. Olher _
Cmilact Person: _. .. _—. __. Phone ll: