24 LEAVITT ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or D 'sh a
One-or Two-Family Dwelling
- .This Section For Official Use Only
Building Permit Number:."'" `T *� *' DateAp�plied:`
i Q
TS Building official(Print Name) _�R x '..Signature
x SECTION 1:SITE INFORMAT N
,,I.1 Properly Address: 1.2 Assessors Map&Parcel Numbers
Lla 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 Requrred Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP',
2.1 Owner'of Record: "
3'bhr. MuCA-: .0 . TdQ-M AMx.55
Name(Print) City,State,ZIP
a y ' -F 97� 979-7S7Y
No.and Street Telephone Email Address
AS SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply),
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify: kCc— Qr2r f
—�,Bripf Description of ProposedWorkz:C,.n tXQ,C fog t,CC.,/e k %/rL,y4,jgje_
SECTION 4:ESTIMATED CONSTRUCTION COSTS =°
Estimated Costs:
Item Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee: $ ? Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ j ❑Total Project Cost'(Item 6)z multiplier '. x -
3.Plumbing $ d 2. Other Fees: $ '
4.Mechanical (H List:
$
5.Mechanical (Fire
Suppression) $ b Total All Fees:
O� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ Q ❑Paid in Full-, 0 Outstanding Balance Due:
F - `— SECTION 5: CONSTRUCTION SERVICES
- a
5.1 Construction Supervisor License(CSL)
(5y:rJQI e U455 i L i a. povS License Number Expiration Date
Name of CSL Holder
Lis[CSL Type(see below) '
S pikaL gN w4y
Type Description
No.and Street .-- *"�
U" Unrestricted(Buildings up to 35,000 cu.ft.)
7✓.�tt: LET ��tS J ����� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
a SF Solid Fuel Burning Appliances
�, 7 5�'7 I Insulation
Telephone Email address I D Demolition
5.2 Registered Home Improvement Contractor(HIC) IGo.7 ROD ;� lii
T_p a�0% /
KQ �Tt{i[rt( �'n 0'l�Q!' C,{- & HIC Registration Number E pira on Date
I-R Company me or HIC Registrant Name
No.and Street Email address
QS tie I A Ax c:A 9 7<6 e6SI -5YI6
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 AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR'CONTRACTOR'APPLIES FOR BUILDING PERMIT
I,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
�a; c , =- t 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 application is true and a rate the best of my knowledge and understanding.
-(o- 2D13
Print Owls or Authorized Agent's Name Electro c Signature) Date
V - ,.. NOTES:
1. 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. og v/dns
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"
1r� �
CITY OF S.0 ENi, N'I1SSACHUSETTS
Bunnns,G DEPARMENT
a
120 WASHINGTON STREET,Sao FLOOR
TEL (978)745-9595
FAX(978)740-9946
1Q\IBI RI EY DRISCOLL
MAYOR THODfAS ST.P[ERRIs
DIRECTOR OF PUBLIC PROPERTY/BCILDING CO%MIISSIO,iER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t licant Information Please Print Le ibl
Name(BusimssOrganizatior{t//Individtml): I l/
Address: Z2i0/ iSaS S�
City/State/Zip: �a S�<c 'APhone #: 2 7 —S�T Z
Are you an employer?Check the appropriate box: Type of project(required):
].a I am a employer with 15 4• ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7• El Remodeling
ship and have no employees These sub-contractors 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
required.] officers have exercised their 10,0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I-El Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12ttaRoof reppaiors
insurance required.)t employees. [No workers' l3 ❑Other. !VL U�.—
comp. insurance required.)
•Any applicant that checks box#1 most also fill out the section below slowing their workexa'compensation policy iniuma soo.
*Ikeneco mrs who submit this affidavit indicating they am doing all work and then hire outside contractors most submit a new affidavit indicating such.
:Connonton that check this box most anached an additional sheaf showing the name of the sub<mmactors and their worllem'comp,policy infomutim.
I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy cared Jab site
information. .
Insurance Company dame: \0—
Policy#or Self-ins,Lic.#: (/../Cc S® i I (1 (-Z d( Z . Expiration Date:t Vz ( '
—mob Site Address: 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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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 certify under f d penalties of perjury that the information provided above is true and correct
Signature: » Date'
Phone#:
OJJichd use only. Do not write in this urea,to he completed by ehy or town offieiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other,
Contact Person: Phone#: