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11-13 LIBERTY HILL AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts (�� uk Board of Building Regulations and Standards CITY ' t 1 Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM Revised January Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, ?008 One-or Two-Family Dwelling is Section For Official Use Only Building Permit Number: Date Applied: Signature: !h/�J��V Building Commis ' r/Insp etor of Buildings Date „� SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers - L l 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 Yazd 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Q �LlOtlntnrl ��Qo�r� 1 - 1 '7J I 0 P.4I� _Ol°l Name(P )¢ Address—for Serlap vice: , �, rint ignaturel �jelepkone-� SECTION 3: DESCRIPTION OF PROPOSED WORK'- (check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other )6 Specify:ftfiJQDM Brief:Description of Proposed Work-: - 54 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 7K 1. Building Permit Fee: $ Indicate how fee is determined: El Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x I Plumbing S 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: S Check No. Check Amount: • Cash Amount: - 6. Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due: 617�9�7� 291,6 SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) N AO� nn U l� Wl l i �/j(/j (/c 1 License/NluTmber Expiration DateL N c CS - older tr List CSL Type(see below) Address IType Description U Unrestricted(up to 35,000 Cu.Ft.) Si R Restricted 1&2 Family Dwelling M Masonry Only o RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Irppr vernent Contractor(HIC) HIC Company Name or HIC Registrar Name IRegistration Number Ad ess 6/-9P/U" E 22, V Expiration Date Sigma 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, _s1ti'�a --6L(k.. . as Owner of the subject property hereby authorize _ �Sys,, co to act on my behalf, in all matters relative to work authorized by this bui ding permit application. r��z & ea o - 6- of Own& FDate Wit,. SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION I, &an G/O✓G riJ ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. pp 7�n2t . 6 ie ve.A CJ Print Name �47 / // y Signature of rized Agent Date a T (Signed and aims and penalties of perjury) 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors 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 halfibaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" • The Commonwealth of Massachusem Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass govAUa Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers Applicant Information _ Naive (Business/OrganizatiowIndiv�ifdu/al)�:,I �+/�,�rVrf N- GL��rt t�^'� V_-K. Address: 140 4ulPtt K G,YA yJ I►JCL l City/State/Zip: Tt Nii1 ( O Phone #: 7�I roof a Are yop an employer? Check the appropriate box: Type of project(required): 1.® I am a employer with 4. 0 I am a general contractor and I 6 New construction employees(full and/or part-time).* have hued the sub contractors listed on the attached sheet. 7. ❑Remodeling 2. I am a sole proprietor or partner- These sub contractors have g_ Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. ❑ Building addition o workers' com insurance comp.insurance. [N P• 10.❑ Electrical repairs or additions required,] 5. 0 We are a corporation and its 3. I qu a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions [No workers' comp. myself. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. ploy §I(4), and employees. [No workers'have no 13.0 Other. comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compeneation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-connadors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy andjob site information.' Insurance Company Name: Policy#or Self-ins.Lie.#: 50074I7el2O10 Expiration Date: 41�/2O/I Job 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 $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$250.00 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 the pains and penalties of perjury that the information provided above is true and correct Signature �� �� Date' Phone# 701-5 91 d y-38 [[6. cial use only. Do not write in this area,to be completed by city or town official. or Town: Permit/License# ing Authority(circle one): oard of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ther ` tn rt pnranw -- Phone#'