4 LEMON STREET CT - BUILDING INSPECTION l q -' ir
18 Z
I 'rhe Commonwealth ofMassachusetts INSPECTIDNA�,JEWCES
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Iola APF a4"A"'S-41
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This Section For Official Use Onl
Building Permit Number: Date Appli
_ S ure' M e
BuilJing Otlicial(Print Nmne). -
SECTION t:SITE INFORMATION
I.I P7Leerty Address 1.2 Assessors Map& Parcel Numbers
Map Number Parcel Number
i.la Is this an acce ted street?yes__ no P
1.3 Zoning Information: 1.4 Property Dimensions:
yy
Zoning District Proposed Use
Lot Area(sglt) Frontage(11) 9
1.5 Building Setbacks(ft)_
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Winter Supply:(M.G.I.c.40,§34.) l.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipnl,TOn site disposal system ❑
Publicr- Private❑ Check if es❑ .
SECTION2: PROPERTY OWNERSHIP, /.
2�wrnerlof Rcco NVd— U R2t�i /� (�. City,State,ZIP
G �� Pi J2 ��( � 1`C� . _ 7 Ut 9-9- 5` oC0. P Cc7 J'�
No.mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Cl Specify:
Brief Description of Proposed Work':
/��_L �. V J - /v L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofltcial Use Only
Item Labor and NIateri:ds
1. Buildin, S 5 v, av O I• Building Permit Fee:S indicate how fee is determined:
❑Standard City/Tgwn Application Fee
2. Electrical S O U O ❑Total Project Costa(Item 6)x multiplier x
J. Plumbing S q--t7U O 2.List: rFees: .S
1. Nlcch;mica List:
I (11VAC) S �j0 U /
i. \Ixh;utiril (Fire S — rural All Fees:S
Su session)
Check No._Check Anwunt; Cash Anunutt:_
G.Total Project Cost: S Gj a 0 UO ❑Paid in Full ❑Outstanding Balance Due:
CPO- .ED L\/I S-- Sip 1T O u q/i
��1�� (Dy
=•�ISEC'flONS: CONSTRUCTION SERVICES
5.1 Cunstruction Supervisor License(CSL)
t ( . n' G"y License Number E.rpuatiun Date
Name of CSL[folder
l.istCSL'rype(scebeluw) U
kdwm 'type Description
Nu. and Street
U Unrestricted(Buildings tip to 35,000 cu. 11.
-x (6t,l j IW,
�p/�_. R Restricted 1&2 Family Dwelling
Cityrt•own,State,ZIP NI Nfasonry
RC Rooting Covering
Dill t6 nn ot�2P` WS Window and Siding
SF Solid Fuel Burning Appl ianees
Cell ( 33$�9CQtrl�µSL, 1 Insulation
'1'cle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
II C Registration Number Gepiru
HIC Cunip:ay Name or f C Registrant Name r /�
f�nf arc crlC �3k 33S�U/COnr�)t.,(tst �
No. and Str�i' t� 'T oil address
,,� �roOW�5 617-��o-3z�F
' Cit rrown,State ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(N1.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 CONIPLETED WHEN.,
OWNER'S AGENTOR CONTRACTOR APPLIES FOR BUILDING PERNIIT
1,as Owner of the subject property,hereby authorize
m behalf,in all matters relative to work authorized by this building permit application.
Print Owner's N 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
this application is true and accurate to the best of my knowledge and understanding.
Print Owners or prized 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
(nut registered in the Flonie Improvement Contractor(HIC) Program),will Lint have access to the arbitration
program or guaranty fund under NLG.L.c. I42A.Other important information on the HIC Program can be found at
iaww.masi.eov'oea Information on the Construction Supervisor License can be found at www.mass."ov'dys
2. When substantial work is planned,provide the information below•.
Total flour area(sq. If.) (including garage, finished basementlattics,decks or porch)
Gross living area(sq. tt.) Habitable room court
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
l)peofcoolingsyitcnt_ Enclosed Oprn_.
1. "I'ulal Pnrjst Syuarc Foumtge"may be iubstiuitcd tim"total Project Coit"
I
Office of Consumer Affairs and Business Regulation
-- 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 170415
Type: Individual
Expiration: 10/18/2015 Tr# 245735
ROBERT ROGERS -
ROBERT ROGERS .
26 WILDWOOD RD
DANVERS, MA 01923
.r
Update Address and return card.Mark reason for change.
SCA 1 0 2CM-05r11 - `-" Address Renewal Employment Lost Card
&7'e W"Jim,antor"S4 a1011lF;�"Cl?raella
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
KnOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration 170415 Type: Office of Consumer Affairs and Business Regulation
Expiration 10/18/2015 Individual 10 Park Plaza-Suite 5170
Boston,MA 02116
ROBERT ROGERS =_...
ROBERT ROGERS
26 WILDWOOD RD Q
a"
DANVERS,MA 01923 f�
Undersecretary Not valid wit out signature
u
1 Massachusetts -Department of Public Safety
Board 041 Building Regulations and Standards
Construction Supcnisor """
License: CS-085322
ROBERT F ROGERS !
26 WILDWOODRD i
DANVERSMA ff1923� .
1% 'J
��¢. ), Expiration
Commissioner 05/13/2015
CITY OF S U EM, NL-�SSACHL'SETTS
BuR wc;DEPART\IEINT
3 �`c Ili 120 WASHINIGTON STREET, 3w FLOOR
TEL (978) 745-9595
F.kx(978) 740-9946
K1\fgERLEY DRISCOLL
1AYOR THOhIAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BCILDL\G CO\NISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(nusinessOrganizaii,iwindividuafl): O nJ— S
Address: 16 IP P -/? fie.., lei
City/State/Zip: Phone #:
Are you an employer?Check tjie appropriate box: 'type of project(required):
1.C�-_I am a employer with 4. ❑ I am a general contractor and[ 6. ❑New construction
employees(full and/or pan-time).• have hired the sub-contractors
2.❑ 1 mn a sole proprietor or partner- listed on the attached sheet.: 7• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working Ibr me in any capacity. workers'comp. insurance. 9. Building addition
[No worked comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
I.❑ I am a homeowner doing all work right of exemption per MGL I I.[] 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' 13.❑ Other
cutup.insurance required.)
•Any upplicarn that checks box#1 must also fill out ese action bclow showing their workers'compensation pa[icy inlbrmatiun.
'I hxnnswt "who submit this aff1d•v,it indicating they ate doing all work and then hire outside can[mctors mint submit a new afridavil indicating such.
:Cmomctum thin cheek this box must almchcd an addidunul sheet showing Ile na,ne of the subsontmcton and Iheir workers'comp.put icy informmion.
/tun an employer that is providing workers'compensation insurance for my employees. Lfeloly 1s the policy and fob site
information.
Insurance Company Name:—A,/ 0���------__—
Policy 4 or Self-ins. Lic. ll::/ ,( _ Expiration Date: /
Job Site Address: y Ll� ,S tl v �v City/State/tip: J 1-P I� Vt'�G�
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 S1,500 00 and/or mu-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine
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
Invcstigwians oi'thc DIA For insurance covcngc vcriticatiun.
/rlu neby c•rrrijy run er tr tuhrs unJ uufties ojperjary 1/rut the injonnutlon provided ubunOtt s tr r and correct.
Phonc
OJficiul usr only. Do not write in this area,to be completed by city ur to ova officiuL
City or'I'uwn: Permit/I.lcense#
Issuing Authority(circle one):
1. Board of Health 2. Building;Departuleitt I.Chyffuwn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Cunlaet Person: — — Phone --
)
h,r
CITY OF ScUzN(, ;ti xs&S CHUSETTS
t�yr 120 WASHLNGTON STTUXT, 3 a FLOOR
r ,n '
T..L (978) 745--9595
Icl3t3F_RLEY Dtt-1SCOLL F-LX(978) 714-9845
A-ma THOSLu ST.PmRRa
DtUCTOR OF PUBLIC PROPERTY/BUIL.OLNG CONWISSIONER
Construction Debris Disposal Affldavit
(required for all demolition and renovation work)
In accordance with tiie sixth edition of the State Building Code, 730 CMR section l
Debris, and the provisions of NiGL c 40, S 54; I I.5
Building Permit it is issued with the condition that the debris resulting fmm
this work shall be
l 11, S ISOA. disposed of in a properly licensed waste disposal facility as defined by t'VIGL c
The debris will be transported by:
y
(name at hauler)
The debris will be disposed ot'in
(name ot't'acdity)
r
L s� L
(address at'tacitity)
si�ttaN
S t permit appfican[
Lu�
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