19 INTERVALE RD - BUILDING INSPECTION 0 The Commonwealth of Massachusetts Town or
Board of Building Regulations and Standards �o*
Massachusetts State Building Code, 790 CMR, Ta edition Building Dept
Building Permit Application To Construct, Repair, Renovale Or Demolish a
One-or Tiro-Funuls'Dwelling
\�(v This Section For Official Use Only
\� Building Permit Number' Date Applied:
Signature:
Belding tsstoneN Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro re AA dress: 1.2 Assessors Map i Parcel Numbers
—" ��2✓��� ��4 Parcel Number
M Number
I.la Is this an acce led street'.'yn : no �
1 ping I:farmatlos: 1.4 Property Dimensions:
2onm Da since Proposed Use Lot Area(sq R) Frontage In)
1.5 Building Setback (R)
Front Yard Side Yards Rear Yard
Required Provided Required I Provided Required Provided '
1.6 Water Supply:(M.G.L.c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zons: _ Outside Flood Zate9 Municipal D On site disposal system D
Public D Private D Check if sD
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Reeo
T,,,,,,�zL J,.. ��d�t-emu tin t`�A�?5�n1 C- I 1•�� -
Nsme Print) J Address ror Service:
� / 17T' &Y--Gale
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cbeek all that apply)
New Construction D Existing Building O Owner-Occupied D Repsirs(s) D Alter
alion(s) O T Addition
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brie xript' n of Proposed Work': � �
.tn.
SECTION♦: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building f 04c>p 1. Building Permit Fee: f Indicate how fee is determined:
O Standard CiryrTown Application Fee
2 Electrical f 2s6 d O Total Project Cost'(Item 6)x multiplier x
Plumbing f if 2, Other Fees: f
4. Mechanical (HVAC) f List: �l
s Mechanical (Fire f Total All Fees: f
Su resaon
Check No. _Check Amount: Cash Amount:
b Total Project Cost f 3Q CLL^.f7 D Paid ., Full O Ouestandmg Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
r.
22Yti7
Lrccnx Number Espua on Dute
N.Iroe of CSL lylder Lne CSL Ty
pe Isee tic-low)—�
Address Description
U JI Unrestricted(up to 33.0W Cu. Ft.
Restricted IA2 Family Duelling
Sry re fS .N 1 %fasomv only
RC I Residential Roofings Covering
Telephone W S I Residential Window and Siding
SF I Residential Solid Fuel Bursitis Appliance Instillation
D I Residential Demolition
9.2 gegls�ed H_ Drat Itryprovemeat Contractor(HIC)
HIC Company Nance sf.o IC R yl grant Name Registration Number
Address L�. `� 2l.2e9lCS
�- -44W .�j'?� ( &F Ex onion Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL/ 2SC(6))
Workers Compensation Insurance afftdavil must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu a of the building permit.
Signed Affidavit Attached? Yes.......... er No........... O
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.
Si arsine of Owner Data
SECTION Ib:OWNER'OR AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent hereby declare
that the statements and informs on on the foregoing application are true and accurate, to the best of my knowledge and
behal
E a
Prins N
Signature o ner or Authorized gent Date
Sr ntd under the tiro and penalties of
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will so 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 110 R6 and 110 R!, respectively.
2. When substantial work is planned,provide the information below-
To Goon area(Sq. Ft.) (including garage. finished bascrincr nice,decks or porch)
Gross living area(Sq. FL) Habitable room count
.Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
TYpe of heating %ysterrs Number of deckv porches
T�peof Coaling syclem Enclo.ed Open
1 "Total Project Square Footage"may he,uh,muied for-'Total Project Cove"
CITY OF S.UXL N1, , L-kSSAC1iUSETTS
BL•ILDING DEPAR1%ffNT
I'O WASHINGTON STREET, 3 o FLOOR
TM (978) 745-9S95
FAX(978) 740-984
p3CBE)tIBY DRISCOLL
THc&tAiST.PIF.R
H Ite
Ey D
DIRECTOR Of PL13LIC PROPERTY/11CMD12NG CO.%L%DSSIONFR
Workers' Compensation Insurance Alildavit: Builders/Contractors/Electricians/Plumbers
-iii1plicant Information Please PrintLegibly
.Nagle (9usirnv.0rW,za6a,%lnJw,dual):
Address: s p JcJoz �
1244,
City/State/Zi Phone M:
Are, a as employer?Cheek the appropriate box: Typo o roject(required):
I. I am a cmploya with 4• Q I am a general contractor and 1 6. New construction
employees(full and/or pan-time)." have hired the sub-contractors
2.Q I am a sole proprietor ter partner- listed on the attached sheet : 7, ❑ Remolding
,hip and have no employees These sub-contractors have I. ❑ Demolition
working rot me in any capacity, worker'comp.insmsaott 9. FdBuilding addition
[No workers' comp. insurance S. Q We am a corporation and its I O.Q Electrical repair or additions
officers have exercised thew
3.Cl 1 am a homeowner doing all work right of exemption per MOL 11.Q Plumbing repairs or additions
myself.(No worker'comp. C. 132.41(4),and we have no 12.Q Roof repair
insurance required.) t employees.(No workers' 13.0 Other
comp. insurance required.)
-Any applicant mar clerks boa Of mtaa AM fill ere tM relics loot"showing their worker'corny stods s policy walla turWa
r t I.vrwowrnes who su6rnis this aAldsvit indicating they»doing all work anti than hie onside dsatracras hear"limit a new,amdmvil idi"ittg rtttik
T.ennato s ohm cheek this ban mutt aas:hed are slditimsl Jrs showing the n ana of the akswnumccan and the4 -who I con".policy Cara mosti .
Ian an employer that/r providing worRars'compensation/nsunnn jar my rarp/eyeaa, slow/s the pellry and Jet slow
information.
Insurance Company Name: (:Wu a LL/ _
Policy N or Self-ins. Lic.N: 'P15UA✓ — j1013 ZtQ Expiration Date' /S! n�A
)obSireAddress: //.N CQ2 1,, n.vzt.ilo tP City/StatwZip: �iclLl�yv
,mach a copy of the worsen'compensation policy declaration page(showing the policy number and expiration deb).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of■
fine up to S 1.300.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S230.00 a Jay against the violator. Ik advimadl that a copy of this statement may be rorwurded to the Office of
Invcahgatiuna ul'the D)IA for insurance coverage verification.
I do hereby c•errij der r red penalties ojper/ery that the infarmanlan provided above is true and c arrect,
ure-
Phone a:
O/jirial use mdy. Do mar write in'hit area, to be cu'np/itd by riry err town w//Je•raL
Ciry or uwn•r - - -- Pcrmit/Ll ---- --- - I
censt N
Issuing .whorily (circle uncy
1. Ituard of Health 2. Building Department 3. City/town Clark J. Elecrrical Inspcclor 5. Plumbing Inipeetor
6. Other
lonlact Pcrion: - --, -.. Phone ow:
CITY OF SALEM
AS/
PUBLIC PROPRERTY
DEPARTMENT
htl: RI P.1 ! Nlw „I 1.
f 20 Wxil ll.\I:I(1N)1'R FLT # S.\I I`\1, NlLKi.\t I II
Tef:v78 7J.+•9.95 Pas:978.740-/846
Construction Debris Disposal Affidavit
(required fur 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
l 11. S 150A.
The debris will be transported by:
I name of hauter)
The debris will be disposed of in
(name of acts ny)
(address of facllny)
--�
4V , 411p, t
i
date
dcln Lal1',:gym