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1 ISLAND AVE - BUILDING INSPECTION (4) 5q 3— �{ 75 Lj The Commonwealth of Massachusetts � Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 730 CNIR SALEM Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised,yur 2011 One-or Two-Fmnily Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Z;r � ' DuilJing Otticial(Print Name) �r-�1.�i � �� ��-} Signature �p p T- 1.1 PrupertyAdtl�ss: SECTION I:SITE INFORMATION _ 1 4-5&&!D 4V6 1.2 Assessors binp&Parcel Numbers I.Ia Is this inaccepted street?yes_ Ito_ hrap Numbcr Fall I al Number L3 "Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Uz--- ,e Lot Area(sq It) Frontage(It) L5 Building Setbacks(ft) reJ ui Re Front Yard Site Yams Rear Yard q Provide) Required Provided Required Provide) 1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: Public❑ Private(3 Zone: _ Outside Flood Zone? 1.8 Sewage Disposal System: Check ifyes0 Municipal ❑ On site disposal system ❑ 2.1 OwneSECTION2: PROPERTY OWNERSHIP' J,t of Reco�1 t (xU pnm 0-ant) 1 --s,CA�-j 0- eve City,State,ZIP NO.ano StMet 60 312- 3 Y8�( Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK?(check all that apply) New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) - Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units f"ef Description of proposed Work': Other [3Specity: rwuuiYn 7rix- . t c VAe— FA)VW bl- 7 e f. iL YL ) Ir�LY'h _ _ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: I. Building Labor and Materials) Official Use Only � $ 3W 1. Building Permit Fee: Is Indicate how fee is determined: 2. Electrical $ wo ❑Standard City/Town Application Fee 3. Plumbing ❑Total Project Cost'(Item 6)x multiplier x 2. Other Fees: 4 4. ,\-Icchancal (HVAC) S List: 5. Me' .11, al (Fire (J Su rcssion) $ Total All Fees:S 6. Total Project Cost: S C�u Check No._C heck Amount: Cash Amount: 2✓ ❑Paid in Pull ❑Outstanding Balance Due: - —` 0� SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name ol'CSL Holder / List CSL Type(see below) skl-MiAwl ©A Type Description U Unrestricted Buildin s u to 35,000 eu.tl.) " No,and Street � r',y^' /- Z R Resvicted I&2 Family Dwellin " � N�� r ' ' `��� / Nt Mnson Cityrrown,State,ZIP RC Root'-in Coverin WS Window and Sidin SF Solid Fuel Buming Appliances r/,t 61 A bd1��ln, I Insulation -70777 �, D Demolition Tele one Emml address 5.2 Registered dome Improvement Contractor("IC) HIC Registration—�b r Expiration Date I11C Company me 05 HIC Regtf a t Name T Yom— �-r Email address No.:u�t Syy'ce�t r `� �� 8ZI e01o%d Tel ephone Ci /Town,State ZIP 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 lsSuan of the building permit. Signed Affidavit Attached? Yes .......... SECTION 7a- OWNER AUTIiORIZATION.TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT` I,as Owner of bject property,hereby authorize /� j t9 act on my ehalf, I matters relative to work authorized by this building permit apphcaho2 �1 l` Date Print Owner's ri lectranic Signa SECTION 7ti:OWNERORAUTFIORIZED AGENT DECLARATION By este 'ng my name below.I hereby attest under the pains and penalties of perjury that all of the information cont.'red in th' up i ' true and accurate to the best of my knowledge and understandinng�g.-�� DAte Pn n Owner's ur Authorized gent' N;une(Electronic Signature) NOTES: 1. An Owner who obtains a building permit to do his/her ow)Workg,or an oi11n'rt`havera cess torthe arbitration tractor (not registered in the Hone Improvement Contractor(HIC Program), can be program or i_ s ."ovz._'oct information'lon the Con-tru tion Supervisor Licertant fnse can be found or ation on the atC Program��'mgr's foundat �. When substantial work is planned,provide the info In illcdt,inylearage finished basement/attics,decks or porch) notal tloor area(sq. ft.) Habitable room count Gross living area(sq. tt.) Number of bedrooms Number of fireplaces Number of half/baths Number of bathrooms Number of decks/porches Type of heating system Enclosed —Open Type of cooling system Footage"may be substituted fur"'Coral Project Cost" 3. "total Project Square Massachusetts,-Department of Public Safety Board of Building Regulations and Standards - Construction supervisor License. CS-07913 DANIELFW" 488 KENDALL RB :. s TEWKSBURYMA 01874 Expiration commissioner 101o5f2015 i Qqg r dq ��no�z cry z dat zcc5e , gi Office o Consumer A airs n usmess a ulation 10 Park Plaza- Suite 5170 X; Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 137943 Type: Supplement Card OWENS CORNING BASEMENT FINISHING Expiration: 1/29/2015 DANIEL WALSH — — ---- 60 SHAWMUT RD CANTON, MA 02021 Update Address and retpra card.Mark reason for change. sca i a zoanosm [_ Address Renewal D Employment F.] Lost Card ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Nr Office of Consumer Affairs and Business Regulation �� SYtegistration: 137943 Type 010 Park Plara-Suite 5170 - "r=te" Expiration:,1/29/2015 Supplement :ard PP Boston,MA 02716 OWENS CORNING BASEMENT FINISHING SYS DANIEL WALSH - 60 SHAWMUT RD CANTON,MA 02021 Undersecretary Not valid without signature oR. CITY OF S.\LEM, NL-�SS.1CHL'SETTS s BUILDING DEPARTNIEINT +� 4jt[ fr'rr 120 WASH NGTON STREET, 3AB FLOOR lb s TFL (978) 735-9595 F.A_x(978) 730-98 6 lU\BERLFY DRISCOLL VYAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/01211-DING COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractorq/Electricians/Piumbers rk i rlicant Information Please Print Le ibl Name ffA1 Address: 60s��, ,,��4yy��% po- City/State/7-ip: Cefw0) /"ffr !)2A?,f Phone If 6y6d Are ya employer? Check/t¢e-appropriate box: 'type of project(required} 1. 1 am a employer with. 3 3. ❑ 1 am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6. ❑Ne construction 2.El ani a sole proprietor or partner- listed on the attached sheet.; 7. Remodeling ship and have no employccs These sub-contractors have 8. ❑ Demolition working fix me in any capacity. workers'comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 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.❑ Roof repairs insurance required.) t employees. (No workers' . I;.❑ Other cutup. insurance required.] '•Any applicant our checks box BI must also fit out the xenon W,owshowing theirworkcn'compensmiun policy in6i motion. I tommrwrwo who whwit this am<twit indicating they arc doing all work and then hire ouuida contractors must submit anew affidavit indicating such. $',,mncWn that check this box must attached an additional Acel showing the narne of the sub-contractor and their workers'romp.policy information. I ant on eurployer Nrut is providinK workers'c•ompeasarlon in.surunce for my employers. Below Is the policy and fob site information. _ Insurance Company Name: S11`1-C I-A)3__ Policy b ur Sclf-ins. Lic. tl: 1!i/l..(/ '028 ? Expiration Datc: �, 1 sr✓v e1A a9'7U Job Site Address: `/�� City/Stair/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 line up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to$250.00 a day against the violator. Be advised that a copy of this statement may 0s: forwarded to the Office of Investigations oft for insurance coverage verification. /oo her11" and penalr/ex of perjury that the information provided'above is true and correct. Si •n t i t' �f. � J Phone 1' 1 Q-Ci/ _1, O dv OJJicit!!use surly. Do rint'rVciie hithis arra,,to be con+pleted by city ur mwm n/JieiuL City ar Town: Permit/l.lcense tt Issuing Authority (circle one): I. Board of Ilealth 2. Building Depirttineut 3.C'iVruwn Clerk 4. Electrical luspector 5. Plumbing lu.specror G.Other Canino I L"nn: Phone Y: [ CITY OF JA zNf, >tiL-USACHUSETTS BL'ILDL%,G DEPARTMENT 120 WASHLNGTON STREET, 3' FLOOR TFL (978) 745-9595 FAX(978) 7409845 KI�tHERL.EY DRISCOLL i1QiYOA THObLJLS ST.PMMa DI.QECTOR OF PUBLIC PROP ERTY/BCILDLNG CONOUSSIONER Construction Debris Disposal At'tidavit (required for all demolition and renovation work) in accordance with the sixth edition of the State Building Code, 780 CMR section l l 1.5 Debris, and the provisions of tLMGL c 40, S 54; Building Permit J# is issued with the condition that the debris resulting from this work shall be d I 11, S ISOA. isposed of in a properly licensed waste disposal facility as defined by rbIGL c Tlia debris will be transported by: 1 COMP (natna ufhauler) "Che tk:bris will be disposed of in : — - (name of facility) (address of facility) i signature of permit applic w '— d:uc OWENS CORNING 0 MEN MEMME ME■■ ■■■.■ �■■■ ■■ 0 MINES■■MEN■■■■■111111 111 MINE ME 0 EMEMEMMEM M No■ ■■■■■ ■ ■■ ■■■■■■■■■■■■ ■M■■■■■■■■■ i.�ri� ■ ■�'r ■■■■ 1��1�■11111■■■■■■■■■■■■�■■■■■■■■■■■ tNN■■� � � No rN/■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ na—=W p " �ME■■MMMOMME■M ■■■■■■■■■■■■■■■MEN ■ ff11 , ■��■■■■1■ 11 ■ ME iii= �MENEMN■�WC: ®NAArE��ENEEMEMEM ■�No�� ` � II■�I�I�I�I �■IO■■■■ ■■■■■■■■ `SMC ...�M�.�i3�►�iE■■■■■■■■■■OEM ■■ a�q FfvM lll��11MEMEME ■■� MrI■Y■ M■EEM■■■MEMO■■■■■� :I ■■ ■■ ■■ Film■��MM■1■■MEM■ ■MME ■ ■■ 2K iiUNIM■■ME■EM■EEE■O■■ H■I■■N■FT■ M■�I M■■■MM■■M■M�■�■E�MEM■■■M■N■■■■E■M■■■■■■E ■O � �� •_ , MM■■ME■■■MMM■■■EM■■■■M■■■■ ` ■M �O■YIE■ � E■EE■OMME■MOM■M■M■■■■■■■■E OWENS CORNING / :' ■: : :■■ ■ : ■ ::::::■■:■■■:■■■:■■■ ■.■■:M■:■■■■■:■■..:■■ 1N _■ :•••;••• :"111::::ME ■■. �: 1111111111M.EEE■■:EEN EME:��::$ 1111::■ ::::■: : EMEM ME MEN a :::::::::■■:: a .1111111:1111::::::NON:: -� w• :C�s'! 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