209 JEFFERSON AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CN1R SALEM
Revised A/nr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Divelling
This Section.For Official Use Only
Building Permit Number: Date"Applied:
Building Official(Print Name) eae
SECTION 1: SITE INFOR1`VIAT N -
1.1 Pr eri y20 Q ddress: 1.2 Assessors Map& Parcel Numbers
so
1.1 a 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 ft) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
/ Zone: _ Outside Flood Zone?
Public L!I/ Private ❑ Check if yes❑ Ntunicipalel-On site disposal system ❑
� II ,,S.E.CTION 2:, PROPERTY O�W�NFRS,H,H''V:
2.ye Glr �Q e �1'1'1Q1 Q tY1 y� • `-Y �!lr F' vl1 D=
Name(Print) City,State, IP
L- LC aC&��tUe-e . qj:3-tO(M a} 3 Mar'am hQ0gEP,1r �
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition Accessory Bldg. ❑ Number of Units__ Other ❑ Specify:
Brief Description of Proposed Work': h 1 ll1 11C
trm Ozx-yr Ott
SECTION 4: ESTI MATED CONSTRUCTION COSTS
Estimated Costs:
[tent Official Use Only.
Labor and Materials
1, Building 1 Building Permit.Fn:S Indicdie how fee is determined:
Electrical S ❑ Standard,City/Cown,Application Fee
2. ❑Total project Cost' (Item.6)x multiplier x
3. Plumbing S 2. Other Fees: S
d. Mechanical (IIVAC) S List:
5. Medianical (Fire $
ession) Cotal:\ll Fees: $
Check No. Clieck Amount Cash Amount
(. Total Project Cost: S ULC) — 0 Paid in Full 0 Outstanding 13alance Due:
SECTION S: CONSTRUCTION SERVICES
S.l Construction Supervisor License (CSL) CS--�_$_�I�'d_'__ )�Z'��Q -zo��
J (�UO�_ _ License Number Expiration Date
Name of CSL Molder
�Q List CSL Type(see below)
C�� �
. and Street/ Type - Description
U Unrestricted Buildin g s u to 35,000 cu. ft.)
'VD trn 1n t-T O'Z`C' R Restricted 1&2 Family Dwellin
City! own, Statc, ZIP ivl Masonr
RC Roofing Covering
WS Window and Siding
SF Solid Eacl Burning Appliances
`�--I�� �i /� �lt✓( I Insulation
relz hone Email address D Demolition
5.2 Registered Home Improvement Contractor(I ) C"o'co -
FIIC Registration Number Expiration Date
FIIC Company Name or FIIC Registrant Name
No. and Street Email address
City/Town, 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATIONTO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as e
ect property,hereby authorize
I o acall to ters relative to work authorized by this building permit application.
Print ctronic Signature) Date
SECTION 7h: 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 is true and accurate to the best of my knowledge and'unders[anding.
Print Owner's or Autlwrimd Agent's Name(Electronic Signature) --- Date
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(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
www.mass.<,ov;'oca Information on the Construction Supervisor License can be found at www.mas .eon;'dL
2. When substantial work is planned,provide the information below:
Total floor area(sq. It.) _(including garage, finished basement/attics, decks or porch)
Gross living area (sq. R.) _ Habitable room COUr[t
Number of fireplaces Number of bedrooms
Number ot'bathrooms Number of half/baths _
Type of heating .system _-__-- _ - —_ Number of decks/ porches ---_--
TypeuFeoolingsy ent-- — —-- Enclosed-----_-----Open —
i ' Fotal Footage' uuty be sub;tinucd for'"fotnl Project Cost"
CITY OF S.1LE�t, ti'L1SS:ICHL'SETTS
BUILDING DEPARTMENT
130 WASHINGTON STREET, 3"FLOOR
TEL (978)745-9595
F.Ax(978) 740-9844
KImn FY DRISCOLL
MAYOR THOD(AS ST.PIERR11
DIRECTOR OF PL13LIC PROPERTY/HURDLNG CO%a1iSSIONER
Workers' CotnpensatIon Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Amilleant Information , f Please Print Legibly
Na1nC t0usitw•syOrpnizatiorvindividual):V'pC.' pr `
Address:
City/State/Z(p�SDYII I a "IFs, Phone#: 11O —(0(00 "—e�� �
Are you an employer?Check the appropriate boxt type of project(required):
I.0 I am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.pyry 1 am a sole proprietor or partner• listed on the attached sheet t 7. Remodeling
/ ship and have no employees These subcontractors have 8. (]Demolition
workingfur ma in an ca aci workers'comp. Insurance.
Y a h• 9. Quilling addition
(No workers'comp. insurance 5. C1 We are a corporation and its
required.) officers have exercised their
10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions
myself. (No workers'comp. c. 152, $1(4),and we have no 12.0 Roof repairs
insurance required.]1 employees.[No workers' )3.00ther
comp.insurance required.]
•Any uppllcard that chucks box rl muse also NII au1 iha sectiuo blow/hawing theta wmkus'compenudon pnfley inlurmmlon
'I hvnouwnw who submit this ollclavil indicating they am doing all work and then him aurside eaatmetors must submit a mew amdavil indicating such
:Cuntmetors that churk this box most attached an additional'hod showing the name of the cob mractors and their workers'comp,polity InfotmaNan.
l urn on euployer that Ir provldlne workers'conspentadon brsurance for my employees Below/s doe policy and fob site
in/arrnallon. f`
Insurance Company Name:. 15h)11 Wal! 'h. IhS.,ranee
Policy#or Sclf-ire.Liu N: Expiration Date:
Job Situ Address: City/State/zip:
\teach a copy of the workers'compensation policy declaration page(showing the policy number and expiration slate).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties at it
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of is STOP WORK ORDER and a line
of up to S250.00 a duy against rho violator. Ile advised that a copy of this statement may be forwarded to the OYtico of
Invesligations tit•t IA fur insurance coverage verification.
l do here y c err y u r r leua/des ofperJury/flat toe Lefi raratlon provided ab ve Js irye and correct
Data: �z-CI� 11'Z.
Phone r!:
OJJic ial use only. Do not iwile in r/der area,to be completed by city at town o1jiHu!
I
Cityar,ruwn: Permit(License#
Issuing Aullrorily(circle one):
1. Board of health 2. Building Department .1.Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _,_ . ___ _. Phonetr'
CITY OF S�U..EE1I, iiiL3SSACHUSETTS
NG DEPARTMENT
3 f� 120 VII.ISHLNGTON STREET, 3" FLOOR
TEL (978) 745-9595
F.+x(978) 740 9846
KIJtBERLF-Y DRISCOLL
;4LANOR THONW ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CONLNIISSIONER
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 c 40, S 54;
Building Permit a# 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 NIGL c
111, S 150A.
The debris will be transported by:
Z DwsAI .
(name of hauler)
The debris will be disposed of in
-----�J (name of facility)
— —_(address of facility)
signature f rmit applicant
, 2-1 t2-
(laic
a.bns.dl dew
Massachusetts Oepartment of Public Safety
Board of Building Regulations and Standards.
Coos ruction Supervisor <
License CS-087188 q
JOSE
83 CRE ST AYE IN s'
R 02151 y
,o
gPN Expiration
commissioner 1y16/2013
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