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22 IRVING ST - BUILDING INSPECTION The Commonwealth of Massachusetts �• Board of Building Regulations and Standards CITY OF � Massachusetts State Building Code, 780 CMR SALEM 7I Revised b/m 20/1 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Divelling This SectioaFordfricia[Use-Onl Buildin Permit Numbers DStp Apphedi;. '.�7 Build Official(Print.Nlime) / v Si natu Data/% SECTION t:SITE'INFORN TION. 1.1 Pro erty Ad.��7?'��ess: 1.2 Assessors Map 8t Parcel Numbers L la 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 tt) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L o.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑ Check if.yesO " SECTION2., PROPERTII'OWNERSHIPL 2.1 Qwnertof ecord: 76) 0 N. Print) - City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK°'(check 1 that apply) New.Construction ❑ Existing Building❑ Owner-Occupied ❑ Rnpairs(s) W1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bidg. ❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Vork3 SECTION 4: ESTE L4,TED CONSTRUCTION COSTS- Estimated Costs: Item OfRelal Use Only;., Labor and Materials I. Building $ 2 1•.Building PermitFee:S` [ndicdte how fee is determined: �. F.Icctricd g El Standard..Cityttown Application Fee ` ❑'rotal Project CosO(Item 6)x multiplier TYYrrr----x 3. Plumbing i 2. OtherFees:'S t. M.chanic:d (IlVAQ S List; i. ,Mechanical (Fire 5 Sn ression) _ Total Al Fces:.'S_ Check No. Check Auwunt: Cash Autouut•. n I'nt:rl Project Cu.it: 5 }-� ���^�. > , /Ltd/ ❑ I aid in Fill 0 Outstanding Valance Una: SEcrION 5: CO;NS'l-RUCTION SERVICES 5.1 Construclimt Sup rvisor icense(CSL) — License Number — Expiration Date Name of CSL I folder List CSL Type(sae below) T e Description No. and Street l� per` ten„ U Unrestricted Ouildin s u to 35,000 cu. ft. _ sX/,ef ,n. k Restricted 1.4t2 Eumil Dwallin Coy/rown,Staff te,ZIP LNI ilason RC Ruotin Covering W$ Window and Siding SE Solid Fuc1 Burring Appliances I Insulation I'de hone Email address D Demolition 5.2 Registered Home Im roven ent Contr.Ypr(H[C) �71Y7S— 3�Ia0/r/ 1 H[C Registration Number Expiration Date L`u pany hone or hIIC Regljtrnnt Nyn �� ��� Email address n S t//�� �n 20Town State ZIP Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. M. § 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 Issuan of the building permit. Signed Affidavit Attached? Yes ..........d No...........❑ SECTION In: OWNER AUTHORIZATION TO BE COMPLETED WHEN , OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT 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. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' 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 applicuion is true and accura to Athl of my knowledge and understanding. rYA Print Owner's or Authorized A;ent's Name(Electronic Signaturep Data NOTES: 1. An Uwner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Hume Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty fiord under M.G.L. c. I42A. Other important information on the FIIC Program can be found at www.m;iss.euvhxu Information on the Construct ion Supervisor License can be found at aw•tvanass.�.•tyvdL 3 When substantial work is planned,provide the information below: Total tloorarea(sq. tt) _(including garage, tinished basctncnt>attics,decks or purch) tiros; living area(sq. III .--- F[abitable room count _ Number of tircplaces_ —_ ----- Number of bedrooms Numberufbathroums Nmnherofh:dG'baths ----_---- t'cpe of heating iystcnt — ---_ Number of decks;pardtes - . ..... -_----- f}peofcoolin" iyucln Euclused_--- (lpcn i. `I,v.d Prnrt.i,e" ni.ty he inbitinu:d rol I'„r.tl Pnq'xt .. .-y. .0 .vw ;�* 'a.-.y.•" `.'r^ ""^""""�'�.:.w'"r..'°�,'."`j .yh.��«...+-..r°".-"rv'. `w 4 '� t '�.P CITY OF S.'1LE��f, l'L�SS. CHL'SETTS BtiILDI�i 3G DEP�RT\tE+�iT 120 WASHINGTON STREET, P FLOOR Tm (978)745 9595: F.tx(978)740-9846: KI.%fB RT EY DRISCOLL Tliob'L4SST.PMRRE gAYOR DIRECTOR OF PUBLIC PROPERYY/BUUMING CO\L%JISS10- EIL Worker§' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Pitimbers Ali licantlnfdrrtiation Prase Prin Le ibl ' Name(Businos%Orgtrnniizatiorvindividmi) ' Address: city/state/zip:_ � �� (DI,> Phonek: Arc y an employer?Cbeck the appropriate box: Type of project(required): I. I am a employer.with'- 4. ❑ I am a general contractor and 1 6. ❑ construction employees(full and/or part-time).' have hired the sub contracidts 2.❑ 1 am a sole,proprietor or paMer- listed on the attached`sheet. �• Remodeling ship and have no employees, :- These subcontractors have S. ❑Demolition working for me in any capacity. workers'COMP insurance, - 9. ❑Building addition [No workers'comp.insurance. 5. ❑ We are a corporation and its ? officers have exercised their 10.0 Electrical repairs or additions required.}" - " 11. Plumbing rc errs or additions [' 3.❑ 1 am a homeowner doing all work right of exemption per MGL, ❑ g repairs ` myself.[No workers'comp. c..152,41(4J,and wb have no 12.0 Roof repeun insurance required.) employees.[No workers' 13.0 Other comp.insurance requircdJ F •Any appllcaot that checks box#I most also rill out the seciim below showing thei worker'compeoeation policy infomutiom t I hnneowiteri who submit this feldsvit indicating they ate doing all work and then hiro outside cuntncton mutt submit anew affidavit indiating,soch. :Conuacton that check this.box must attached an a4lidonal sheet showing the name of the tuMcoatrwtors and their'worken'comp:policy infotinatien.. !um an employer that Is providing workers'compensation lnsuri mce for my employeesc Below Is die policy and fob site information., Insurance Company dame: Policy#or Sclf--ins Lie.#: - `C2o?S-7G a(r� ,.� - Expiration Date: Job Site Address: 122 sti/�ry�/ CitylState/Zip: Attach a copy'of the workers'compensation policy declaration page(Showing the polley number and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$230.00 a day against The violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance cove agcverification. l do hereby eerdfy a tr t ah, d Pe allies of perjuay that the information provided obove is true and correct Phortco` -- Ojjicial use only- Do not write in this area,to be completed by city or town ojjklol City or Town.- PcrmitRaeenye# Issuing Authority(circle one): 1. Board of Health 2,Building Department 3.Cilyrrown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: __ Phone#: L_. tl I � 1 r- ,. CITY OE S:1C.E,1,! ttiL155.1C HLSETTS i'(:=LNG DEPAR-M&NT WASHNGTON STREET, SiO FLOOR TEL (978) 745-9595 KIJ(aE.`tLEY DRISCOLL F-V<(973) 7.10-934,5 r UYOR '[�tosc�Sr.PtERRs DfZECTOR UP PULIC PROP ERTY/a t:MDLNG CONLIUSSIONER Construction Debris Disposal At'ttdavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Coda, 730 C��iR section 111.5 Debris, aid the provisions of MGL c 40, S 54; ©uilding Permit tt is issued with the condition that the debris resulting from this work shall be disposed of in a property licensed wosta disposal facility,as defined by t%,IGL a 111, S 150A. The debris will be transported by: (nantn ut'haulur) - The debris will be disposedot'in : (nnma ar t�cility) �-- (ids rt5s ot'ra:ilil%) ;i�tu rafpamit.rp icant