25 LIBERTY HILL AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts °°
CITY
Board of Building Regulations and Standards I
d Massachusetts State Building Code, 780 CMR, 7" edition OF SALEM
Revised January
t Building Permit Application To Construct,Repair,Renovate ORfa1iOE01t a 1, 2008
_ One- or Two-Family Dwelling INSPECTIONAL SERVICES
This Section For Official Use Only,
Building Permit Number. / Date Applied:.
Signature: �aM..w
Building Commissioner!Inspector of buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
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 III) Frontage(fk)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L cc.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❑ a
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Tr,eodore I oros.�an aS L1 6er( � —
t3ame(Pr' Address for Service:
—'
r7 % --7yS - st25
Signature Telephone
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. l7 Number of Units_ I Other ❑ Specify:
Brief'Description of Proposed Work': -i�Qh o,1 dt C 1-,.m n e —n s+ca 11�-t-��l
Jy�.e.r•
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs. Qi3icia[Use Only
Labor and Materials
I.Building $ 3 600. OU 1. Building Permit Fee: S Indicate how fee is determined:'
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item G)x multiplier x
3.Plumbing $ 2. Other Fees: S ;
4. Mechanical (HVAC) $ List: _.
5.Mechanical (Fire $
Suppression) Total All Fees: $
l
Check No. Check Amount: Cash:Amount
ti. Total Project Cost: $ 3 Sr00 .0 0 ` Ba "`
❑Paid in Full ❑Outstanding Baat�ce Due:Due:._..
N 5 f-\ U 1- : SOH O — CAI 6 1 LfLl - 6oh I
6AL� L, YD Li 19 - U - Q- -S,LtGA -r ) I t? Ct Lt -10CD)
% SECTION 5: CONSTRUCTION SERVICES
f+ 5.1 Licensed Construction Supervisor(CSL)
E53CciS 2 - 13 - 1�
a®k n W 0 I S(1 License Number Expiration Date
Name of CSL-Holder List CSI.Type(see below) (�
5 O Ark st Sa IJ rya
Address Type Description
�� R Unrestricted(u to Family
Cu.Ft)
Si ature R Restricted 1&2 Famil Dwelling
_
M Masonry Only
�7�" y y - o-o-I— RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation.
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 14 k 42�S
_J o.1'1 QC..I S.I�
HIC Company Name or HIC Registrant Name Registration Number
.5 � O'rL�tArC� S'Y�. SPtilt:l'Y� 27• ( '
Ad
ry d -
r;5?/,� Expiration Date
Si ature 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 .......... SP No ...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT ORCONTRACTOR APPLIES FOR BUILDING PERMIT
1,_—The oA rL -1 br_b�CP:lrl as Owner of the subject property hereby
authorize �)o t..Da.1 Sh to act on my behalf.in all matters
relative to work authorized by this building permit application.
Sr 8ture of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1,_�)oh n LJ G.I s h 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
-J h LJals h
Print Name _ / /
���-ate-
Signat a of Owner or Authorized Agent Date
(Si ed under the pains and penalties of riu )
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 and
Construction Supervisor Licensing(CSL)can be found in 780 C41R Regulations 110.R6 and l IO.RS,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 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 COsr
CITY QE SiU.E. I, N-LNSSACHL;SETT5
a i UaztNG DEPARrNiENT
' r< t20 WASHCVGTON STREET, 3ie FLOOR
TEL (978) 745-9595
RAa(978) 740-9846
CX(BERLEY DRISCOLL
MAYOR THonks ST.PIERR6
DMECrOR OF MBLIC PROPERTY/13 V ILDING COtLMISSIONER
Workers' Compensation insurance Afedavit: Builders/Contractors/Electricians/Plumbers
Aonlicant information Please Print l e ihiy
�1
Nalnc(0usit cssOrganizatiu vfndividuaij: T l CO
Address: 5 2 0 r c k tt-r Cp S t'
Cily/State/Zip:__Sa14r , rt,n 0ici -)o Phonetf: 9-7fr 7Yy - iO t
Are you an employer?Check the appropriate box: 'type of project(required):
1.M 1 am a employer with_z _ a. ®' 1 am a general:contractor and i 6. Q New construction
employees(full and/or part-timeyi, have hired the sub-contractors
2.1] 3 am a solo proprietor or partner- listed on the atrached sheet: ? 0 Remodeling
ship and have no employees , These sub-contractors have S. C� Demolition
working for me in any capacity. workers'comp, insurance. 9. (�Building addition
(No tvartteix'comp, insurance 5. (� We are a corporation and its
required.) officers have exercised their 10.C]Electrical repairs of additions
3.❑ I am a homeowner doing ail werk right of exemption per MGL I I.O Plumbing repairs or additions
myself.(No workers'comp. c. 152, $1(d),and we have no 12.[] hoof repairs
insurance required.)t employees.LNo workers'
comp. insurance required.1 l3.O Other.
;Any applicant that decks box it most also tilt our the x�ctioo belowshowing their workers'Sumpenarion policy ineormation.
'I lomdownc"who autwilt this affidavit indicating they ate doing ell work and then hire outside contractors most submit a new air.davit indicating such
=Gintracton that chwk this bus mist anachcd an additional ehmi showing the name of the subeontnoon and their workers'sump.policy infatuation,
f urn an employer than is providing workers'cotopenradatt irrrurance for toy eorplayeez Bolaw is the
iuforniarloa po!!cy antiJab site
insurance Company Vaine: !-t by r y Yy1 u�u 4
Pulicy.4 or Scif-ins. Lic,tl:� S 3 1 S (, O S 3 0 �I 0
I y�_ Expiration Date: (� -S 11 S'
Job Silt:Address: -AS Lt �o e r y hill (A-J p City/Statelzip: P, )9-7)
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 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or onoyear imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine
Graft to S250.00 a day against the violator. 13e advised that a cagy of this statement may be forwarded to the office of
hlvestigaliutts ufihe DIA for insurance coveragc verification.
/do hereby certify 2der tiro patios nand pettuldes of p¢rjury)fat the Lrforruudoo provided above is true and correct.
S',Iwt * eV.111 i�
17/1idol use only. Do not write in drzv aria,to be cotopleted by city err town n/Jiriut i
1 City nr'ruwn: Perm it/f.1ce"go g� 1
tssaing Authority(circle one); -
1. Board of Ilealth 2. f3uiiding ilcparttnent 3.Citylrotvn Clerk. ;. Electrical lnspector s. Plumbing inspector
6. Other
Contact Persnn: Phone tt:_ _. -.
t,1
j Massachusetts -Department :)f Public Safety -
Board Ot Budding Regulations and Standards
Cmistructi,m Superi i%.:r
License' CS-083B15
JOHM WAL3H
52 ORCHARD Si q1
SAL--FM MA 01970
Expiration
Cornrnissfor,er 0211312015
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- _ -00iee of Coosamer affairs&Business Regula0oo
J g%---HOMEIMPROVEMENTCONTRACTOR
'Re9Lstra0On: 148428 T
' 'ExPirddOn: 927f2015. DBA Type:
THE CHIMNEY COMPANY
JOHN WALSH
52 ORCHARD ST
SALEM.MA 01970
Undersecretary