47 LIBERTY HILL AVE - BUILDING INSPECTION The.Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR SALEM
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: Date Applied: S
Building Official(Print Name) Signature
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
47 LS13f12N N LU,�11/EAfUE
1.la 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 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'
V wner of ecord: 1brn ) no
_I C,� jam,' m� Ql ry r7C
dame(Print) j,,,,'"�_ '( , City,State,ZIP "I /(�
*41 UbrN I'h)) hVe, 8•MNDO �0.ustlnval►eu� o,C�m
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction El Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
9XT£k_� rY��To c nylkk 7E�eF- rrnt e pouyl T� IJ�G) fv�l
IJE*t5�3-00 Ill vha��
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5..Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 5 (VM. tV 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Mg�'�.�5
� �rj iJ
�fAQ V/),Uy{ tit QU-cL� License Number Expiration Date
Name of CSL Holder
�q ��H�1 `�� -kV 1`ue List CSL Type(see below)
No.and Street N [iN Type Description
inn/�1� I Lf s y� inn/ (� I q1.l U Unrestricted(Buildings s u Dwellito ng
00 cu.ft.
'1 I/Y� �J R Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
�/ �✓C�.I tIr Y-t�'t-t�'v` I insulation
Telephone Email address D Demolition
5.2 Registered
Rome Improvement
Contractor(HIC) 41446 T1Z7 2
Vy1 `yjLLcc:f�-�3(2L)Tt} GHIC Registration Number Expiration
Date
HIC�.0 p ny Name or HIC��tI3�.,egi tram Namc ����0� ^��� GO
Email address
City/Town,State,ZIP 1 IAA "�'1_ J IJ 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 ..........PP No ...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize �I� 6 ( V N-K)Oucc[
to act on my behalf,in all matters relative to work authorized by this building permit application.
* &nne4h K 51g111
Print Owner's Name(Electronic Signaturki Date
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 accurate to the best of my knowledge and understanding.
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 halfibaths
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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
l I Congress Street Suite 100
� Z, Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrgaJttizatlion/Individual):
Address: AJcl T�i I�4��V� 7kVl�i A E, p
/ tt44 �
City/State/Zip: iU� �� he Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation 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 must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information. G. 1 6
Insurance Company Name: l l I
Policy# or Self-ins.Lic.#: \ )�LO IJ_12U �2_ Expiration Date: , y
Job Site Address: �4'7 Ll� (�(� {�✓ ��+�l�l City/State/Zip:.rIJ—� .L 1/� �UJYVI
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 certi under the ains and enalties o erjury that the in ormadon provided above is true and correct
Date 7
Phone#
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
IAmerion leaelNe4 ine.
_. J