214 JEFFERSON AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
,4,. I Board of Building Regulations and Standards CITY OF
g Massachusetts State Building Code, 780 CMR SALEM
`i Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D plie
Building Official(Print Name) Sign Date
SECTION 1:SITE INFORMATION
L,P�per�y�dc{rgcs: r �� 1.2 Assessors Map& Parcel Numbers
�,tt TT",' $ SCVI
I.to 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 li) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(NI.G.L.c.40,§54) 1.7 Flootl Zone Informatiou: 1.8 Sewage Disposal System:
Public❑ Private El Zone: Outside Flood Zone?
-- Municipal ❑ On site disposal system ❑
_ Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: f, A
—�1Lwh_ fwtG�---- — _�.��w 1t/I /7 �/ i(� --- - -
Namc(�Print City,State,ZIP
No.and Street 'telephone _ Elnail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ I Alteration(s) l7 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units _ Other ❑ Specily:
jBrief Description of Proposed Work`: f
� I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ , i O0 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x -
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
// Check No. Check Amount: Cash Amount:
G. Total Project Cost: $ 61(Q /� ❑ paid in Full ❑Outstanding Balance Due:
J —
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Su ervisor License(CSL) pb - �O /1
kleyl�u l� Cots License Number Exp ation ate
Name of CS .Holder
7 2- P A List CSL Type(see below)
No.and Street T��"L-- /� Type Description
<o (zm �-���`� U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,�LIP R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
q-7a- 1 I Insulation
e Tele honr— Email address D Demolition
5.2� Registered /Hryjome]I�mprovement.C{.ontractor(HIC) % 7&� �O 1 z6
1.
(i Ir Oy VN C), UP CaY+Sr �'tAG'I'L�y� HIC Registration Number :xpira ion Date
HI Company/CCo��mpp�any Name or HIC Registrmt Name
�G .\ r,,rG��
N6-and 'treet 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 .......... a No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Witcx (k U C.rc�cvt�' `"ti'
1,as Owner of the subject property,hereby authorize h A �6 � ray,1_+/'tACf'toi'�
to act on my behalf, in all matters relative to work authorized by this building permit application. . 1
�-_/ 7:. // 5'
Print Owner's Nam Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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 understanding.
T401 es 7t✓r M4M
Print Owner's or Authorized 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
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CITY OF S V.EM A-1SsxfiUSETTS
` B(:ILONG DEP:IRTJL&NT
130 W-UHNGTON STREET, 1.m FLOOR
4. ., T EL (978) 745-9595
F-�-x(978) 7-W-984S
1UJlBEi2LsY DIUSCOLL
ib AYO;t TTiOSG�SST.Ple^.RR$
DIRECTOR OF PU3LIC PR0PERTY/8CILDLYG COSL\tISSIOaER
Construction Debris Disposal At'tldavit
(required for all demolition and renovation work)
(n accordance with the sixth edition of the State Building Code, 730 CMR section it 1.5
Debris, and die provisions of NIGL e 40, S 54;
Building Permit fk 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 ��ICL c
111. S I50A.
The debris will be transported by:
y
y ��t� I JrS�sq I
(aa toufhauler)
The debris will be disposed of in :
ot't'acdity)
(aJdres.t o1'racility
"guatureorv, 1 applicant
,i re
CITY OF SAI EN1, AkSSACHUSETTS
t BUILDING DEPART\IE.NT
120 WASHNGTON STREET,.3aa FLOOR
TEL (978) 745-9595
FAx(978) 740-9M
KINtBERLEY DRISCOLL
vLAYOR THOMAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CO\L\1ISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Picase Print Le ibl
Name (Business.Organizatinn,'Individmd): pr p
Address: "/ L/9 i\ ( t rc I2 - 3[� !fp
City/State/Zip: Phone #: —S S 7^
Are you can employer?Check the appropriate box: 'type of project(required):
1.4 1 am a employer with-:�) 4• ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).` have hired the sub-contractors
2.❑ 1 ann a sole proprietor or partner. listed on the attached sheet.t 7. ❑ Remodeling
ship and have no employees These sub-contractors have N. [] Demolition
working for me in any capacity, workers'comp. insurance. y, ❑ Building addition
[\'o workcti comp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME] Electrical repairs or additions
3.❑ 1 an a homeowner doing all work -right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers'cutup. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
Gump. insurance required.) l3.❑ Other
•Any applicant I tat checks box AI must alsu fill uuI the scaiun betowshowing their workers'cumpensariuo policy oatj anon.
;I hnncuwm"who submit this anldavir indicating they are doing olI work and then him outside contmctora most submit anew affidavit indicating such.
�Cmurxlon Ihot check this box most anach d an additional soul showing Ilw mmne of the sub4°ntnetors and their workers'comp,policy information.
I am an entplayer ilia!is providing Iverkers'compe+tsat/on insurance for my etnplayees. Beloty/s the policy and Job site
inforraalfon.
Insurance Company .Name: ______
Policy a or Self-ins. Lic. 0: Expiration Date:
Job Site Address: At 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 ofcriminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Investigalioas uftho DIA for insurance coverage verification.
I rlo hareby certljy under the pains and penalties'of perjary that the hi/arination provided above is true wed correct
�I'AI;IIIIfC' Date:
Phone '7'
n/lic'ial use only. Do,tor write in rhiv area,to be completed by city or towrr gj1ciai
City nr i'ownt _.__.. . .__ PcrmitR.lccnse#
Issuing.luthurily(circle one):
L Board of health 2. Building Departntcut 3.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact I'ertnn: _. _ Phone 7: