10 IRVING ST - BUILDING INSPECTION -7zD
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The Commonwealth of Massachusetts CITY OF L SERVICES
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Board of Building Regulations and Standards Q � 1
i I' Massachusetts State Building Cod 780 CNIR e, �j y
� Rests d: �� �' 38 ,
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Appli _
Duilding Ot'ticiul(Print Name) Signature /; Date /
SECTION I:SITE INFORNIATION`
I.1 Property Address: 1.2 Assessors Nlap& Parcel Numbers i�D,Z�f ern [, s
I.la Is this an accepted street?yes no Map Number Parcel Number
LB Zoning information: 1.4 Property Dimensions.
Lot Area(s it)— Frontage It
Zoning District Proposed Use 4 g O
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided l
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTIONZ: PROPERTY OWNERSHIP'
2.1 Owncrt of Record: / �0 XAV,
�F//� lam@ i✓Fi U
,•�hme(Prue)' City,State,ZIP
No.and Street Telephone Entail Address
SECTION J: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ 1 Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ I.Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Briet'Description of Proposed Work-: ' Q�a— S �!�✓d-�� ) STOZ!!' A ND
/ EZCpz; IA15S -®ZG 7Gr26 5 t LlGh�7-P
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labur mtd��laterials) !
I. Building $ s'0— 6 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard CitylTown Application Fee
2. Electrical S -- ❑Total Project Cos1u(Item 6)x multiplier x
PIg S 2. Other Fees: S
cal (NV.\C) S List:
rd (Fire rued All Fees:n) Clieck No._C'heckAmount: Cashrnject Cost: S �U ZO 0 Paid in Full ❑Outstanding Balance Duo:_
DOO Cal-AS
1
OTAY 39
SECTIONS: CONSTRUCTION SERVICES
5.1 C'pnslruction Supervisor License(CSL) Qf77G'/ 7 16 ,2
g£ :1 : Nell 1/,- I
U:/,,Z S 4,rek-a16 License Number Expiration Date
Name of CSL Holder
List CSL'rype(see below) I
"r Description
Nu. and Street
U Unrestricted(Buildings Lip to 35,000 cu. R.)Restricted 1&2 Family Dwelling
Cityflmvn,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
5 SF Solid Fuel Burning Appliances
(Q� �ja/Slpr /S�CrPaS' " �aQ�¢ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /3.0.-3 6./
-0e,a Gdn 611,11 IIIC Registration Number Exj irution Date
TIC Cuntp;my Namc or fllC Registraltt Nauru:
t �
No.'aialSurect Email address
Cif (rown,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 Is4uance 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 PERAHT
1,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.
Prim Owner's Namte(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 application 's true and accurate to the best of my knowledge and understanding.
, -6
Print Owner's or AuthorizedAgent'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
(nut 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
ww 9 ntass. ov'oca Information on the Construction Supervisor License can be found at wtvw.in:usaoehlL
2. When substantial work is planned,provide the information below:
rural flour area(sq. 11.) (including garage, finished basement/attics,decks or porch)
Cross living area(sq. 11.) Habitable room count
Number of fireplaces. Number of bedrooms
Number of bathrooms Number of halt/baths
Type of heating systeut Number of decks/porches
Type otcooling system f_ncloscd Open
1. "foul Project Square Footage"may be sub>tilutcd fur"Total Project Cost"
u
1�t Massachusetts -Department of Public Safety
F.". Board of Building Regulations and Standards
Construction Supcnisnr
License: CS-087797
11.-` 11, p
DOUGLASSAREYAL ;; '
50 FuBer. 9
EVERETT MA 02149
Expiration
.. Commissioner 10/29/2015
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:^ :a � a .. V28 �OO?IN/td)WM.UGJLO C SIdC
� ("k Office of Consumer Affaln&Bushl i RRC911 atlo, x
91,
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ME IMPROVEMENT CONTRACTOR=" K
f +, glstra0on 138301 k %Type M N.
xplratlon 3119/2015 a ,
y rs-F a-- ry::�Mr
,, DSC PAINTING AND'CONSTRUCTION*,�
DOUGLAS AREVALO'� .. `
.r'50FULLER ST.. w -' `.,,` —'-+�� :.t;
AEVERETT MA02149"e'/ y?sr—`y, rM. Undenecretarya
,w >.:x.+�kawbS'w.i«„Ta."�.i-M,�.. ..rX` e r ..n, •'nN'
DSC construction
Dscacastro@aol.com
Phone: (617) 592-1561
fax: (617) 381-6997
Proposal
To: Kelly McNeill
Address :10 Irving st Salem MA 01970
Work description
WINDOWS
-------------------------
Installation of 5 replacement windows
Legally dump the old windows
Insulate side wall before installation
The new windows are high efficient .
Seal every windows trim after installation is complete
Strip old roof
Install new asphalt shingles roof
Install two sky lights
total $8,500.00
Cost f the project $ 8,500.00
Any question give me a call at 617 5921561
tro (contractor) J
Home owner Acceptance/ �Z2 date
r
The Commonwealth of Massachusetts F�Prinf Form
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information p / Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:2—�/Ye-' b Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.2 I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).
• have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in an capacity. employees and have workers'
y p ty• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ` �/f
Insurance Company Name: 7/Cell",/� •1t?l eo
Policy#or Self-ins. Lic:#: WO v aO Z" Q 7r Expiration Date:
Job Site Address:/0 City/State/Zip:
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$t,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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certijy der the pains and penalties o er'ur that the in ormation provided above is true and correct.
Signature ---- -- ----- --- Date: -- —
Phone#: tUl;1 59a 15 �l
Official use only. Do not write in this area, to be completed by city or town officiaL
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#:
r
CITY OE S:U ENf, ;ti NSSACHUSE'ITS
l3 :=LNGDEPAMLEYT
130 WASHIINGTON STREET, 310 FLOOR
I'aL (978) 745-9595
F.Aa(978) 740-9845
K1�tBF_RLBY D8ISCOLL
MAYOR T1qoS4ls ST.P1EM
Df.ZECTOR of puaLIC PROPERTY/HCILDLN<;CON
L\IISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section t l 1.5
Debris, ,uid the provisions of MGL c 40, S 54;
Building Permit 1# is issued with the condition that the debris resulting from
this work shall be ll, S ISOA. disposed of in a properly licensed waste disposal facility as defined by r'Y1GL c
l
The debris will be transported by:
1
(nama orltauler)
The debris wi11 be disposed or in
(narne of racdity)
�Z.ev2n3 6v/p
------(al(Iress or raelllly)
1
siguatnre()(permit applicant
�3 �-o //�
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