25 HORTON ST - BUILDING INSPECTION (2) n(I -T-13 - l (-I — 3 Cr-
The Commonwealth of Massachusetts REC IVEqfjlltorFg
Board of Building Regulations and Standards 1NSPECIIC XL SALEM
' Massachusetts State Building Code, 780 CMR R vi, dbr frol
as��
y Building Permit Application To Construct, Repair, Renovate Or Der� l
pll
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Dale Applied:
\ ,. .
'�•� Building Signature �-Olticial(Print Name). ,. �.-
SECTION L•SITE INFORMATION:
L1 Property Address S�( 1.2 Assessors Map&Parcel Numbers
r /„.. , �
M1la
I.la Is this an accepted street?yes no P Nunber Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L C.40,§54) 1.7 Flood Zone Information: I.g Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
----------------
2rofRecord:
lgnrne(Print) P fAu O/' C tly�ale,ZIP
�y— S /%
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ PtOt�herU
Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Specify:
Brief Descriptors of Proposed/WAork=:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
$ I. Building Permit Fee:$ Indicate how fee is determined:
I. Building
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(item 6)x multiplier x
3. plumbing $ 141,(gtherFees: S
4.�itechanical (HVAC) S - List:
c
5. Mechanical (Fire S Total All Fees:S
-Suppression)
Check No. Check Amount: Cash Amount:
G. 'Putal Project Cost:
S t)O VT ❑ Paid in Full ❑Outstanding Balance Due:
(Y\O,A Lib I l( I LA .(3
SECTION 5: CONSTRUCTION SERVICES
5.1 Cmistruction Supervisor License(CSL) 7Q6
•+ f l� ���� License Number .r ra ' n Date
Nome of CSL ffulder� ` . � List CSL Type(see below)�z-
Type Description
No.a; Street Un
Street 1 s-
�`� reslricleJ(Buildings tip to 35,000 cu. tl.
Aell�l �-/� /J R Restricted 1&2 Ft unify Dwelling
City/Town,Slate,ZIP M Masonry
RC Rooting Covering
7 1 WS Window and Siding
��_F SF Soli)Fuel Burning Appliances
gzl"�37✓ _
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) s" L
//(, f -5/ r7j / [/C�(�r F'� - IIIC Registration Number F.s vatian Date
HIC C-rynp:my Niame or HfC�liggtstrant Name
N and Sveet/q� /�.�7 Email address
lFit%fown,S te,Z(P Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.Qll F. 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 PERrmT`
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED 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 o best of my knowledge and understanding.
ace e t t
Print Owner's or Authorize Agent's Name(Electronic Signature) Dt to
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(FIIC) Program),will not have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
w+vw mass.cov:'oea Information on the Construction Supervisor License can be found at www.mass. o+:'dL .
2. When substantial work is planned, provide the information below:
'total floor area(sq. 11.). (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 haRlbatlts
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open_
J. "total Project Square Footage" may be substituted f'or"'fot:d Project Cost"
.F
V Wa"'meP°w�uu,�ry ulatiou
1
ee
cc
ee
tfice of Cousuroer Affairs&BusioCTOR
MEIMPROVEMENT CONTRA yY
y
Registration: t54544 Supplement:
Expiration: 3I19/2095 CTING
OLASSIC STRUCTURES CONTRA
SCOTT BARBEAU
s P.O.BOX 504
BEVERLY,MA 01915 - Under
Massac usetts -Department of Public Safety
' Board ofBuilding Regulations and Standards
Construction Supervisor-0767
License: CS-076780
SCOTT G BARBEAU
242 DODGE ST'6191
TO
BEVERLYMAv" ,n+� Expiration
��'�7"' 071071201j�,
Commissioner
, y
QTY OF SALEK MASSAQHUSEM
, . uLDING DEPARTMENT
120 B,
WASHINGTON STREET,3AD FLooR
nL. (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISGOI-L
MAYOR THomm ST.PIERRE
DIRECTOR OF PuBLIC PROPERTY/BLIILDING COMMISSIONER
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 c40, 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 deposit facility as defined by MGL.c 111, S 150A.
i
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
pu
(name of facility)
(address of facility)
Signature of applicant
Date
T° Q-1-Y OF SALEM, A-1SS:ICHUSETTS
BUILDING DE PART>fEINT
120 \V.\SHLNGTON STREET, 3w FLOOR
TEL (978) 745-9595
F.ALx(978) 740-9846
KINIBERL.EY DR15COLL
r;vy,�YOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUB.DrNG CMNISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Inforrnation / Please Print Leelbly
NalTIC(IlusirxssOrgmtimtina.•Individual): G/G JJC rtL
Address: e U
City/State/Zip: Phone tt: Js 7
an employer"Check the appropriate box: Type of project(required):
1. I am a ens to cr with 4. ❑ 1 am a general contractor and I
P Y 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ i ran a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have S. C] Demolition
working lbr me in any capacity. workers'comp. insurance. 9. Building addition
INo workers'camp. insurance 5. We are a corporation and its 10 Electrical repair or additions
required.] officers have exorcised their
3.❑ I arts a homeowner doing all work right of exemption per MGC I I.❑ Plu bing repairs or additions
myself.(10 workers'comp. C. 152, §1(4),and we have no 12. oorrepairs
insurance required.) t employees. [No worker' 13,�Other
comp. insurance required.)
-Any applicant owl checks has 01 mttat also rill um the surliun hsdow showing their workers'comperoatlun pulity infumation.
'I lomuowncv who submit this X1,11 vil indicating they am doing all work and than hire outside contractors must athmil a new amdaril indicting such.
:t'umtxmn IAu1 chak Ibis box mat aaachd ae additiurul shut shuwing rho mane of the subsonlnctun and their worken'comp.pulley infumlalien.
I unl an employer that is providing workers'compenradan insurance for my employers. Halms/r the pol/ry and fob site
iafwnrufinn. L
Insurance Company Nanne:_.A�Vls1P^ ,_ I / /
Policy it or SclGimi. Lic. ,+/ 6 I�V�7 Q / elvation Date: �7
Job Silt Address: J �-/ ,(D140 ) ! . City/State/Zip: _
A ttacb 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 orMGL c. 152 can lead to the imposition of criminal penalties of
line up to S1,500.00 undiur ate-year imprisomncnt,as well as civil penalties in the Cann of a STOP WORK ORDER and aline
of up to S250.00 a day against rile violator. De advised that a copy of this statement may be rurwurded to the orree of
In vcstigotiuns of the DIA for insurance coverage verilieatiun.
I do hereby eerd/y under Um puhrs and penoldrs of perjury that Jan fnjuratudI provided ubuoe is true and c'orrece
Jc11.n11rc: ZZ // Date: b-) /l7
Phoned, 7kO��
0
Official use mtly. Do not rvrife fo tiI area, to be completed by city ve to run o/Jle!"I
City or
Issuing Aulburily (circle one):
1. board of lleallh 2. Building Departa.nt .l.Cityfrimn Clerk 4. Electrical hupector 5. Plnnibing luspecmr
b. Other
i Cunlacl Perin,): Phone ;t: I