49 LIBERTY HILL AVE - BUILDING INSPECTION The Commonwcalth of Massachuscits
►�, Board of Building Regulations and Standards #*ksomwkoa
a� Massachusetts State Budding Code, 780 Ch1R, T"editionja
pt
Building Permit Application To Construct. Repair. Renovate Or Demoli
One. or Tuo-Fmrtilc Dwelling
is Section For Official Use Only
Building Permit Number Applied: q
Signature: 1 s Z2• a
Budding mmissioneo In Or ddmgs Date
S r ON 1: SITE INFORMATION
1.1 Prope�rt^�y Alddress: /L 6 1.2 Assessors Map& Parcel Numbers
�L y h � �L/ I-I• ��
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 Arca(sq fl) Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c. 40.154) 1.7 Flood Zone Information: 1.9 Sewage�On
posal System:
Zone: _ Outside Flood Zone? Municipal❑ site disposal system ❑
Public Q Private❑ Check if es0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Retord: U
GUMlAM 11/ //JAR- W Aoe
Name IPrint) Address for Service:
r9/9— 9-f3 — 5'7
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKr(cbeek all that apply)
New Construction❑ Existing Building O 1 Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ A------ryBldg. O Number ofUnits1_ Other ❑ Specify:
Brief Description of Proposed Workr: -l-R� �✓L. a r�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OlHclal Use Only
Item Labor and Materials
I. Budding f I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical S Cl Total Project Costs(Item 6)x multiplier a
Plumbing f 2. Other Fees: S
4. Mechanical (HVAC) S List:
S Mechanical (Fire S Total All Fees: S
Su ression
Check ro. _Check Amount: Cash Amount:_
6 Total Project Cost f g5eo• ❑ Paid in Full ❑Outstanding Balance Due:
\ A t �Y /�
'AC'd --,,
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 6oSgz9 g—,is-- //
46Q, -A f License Number Expiration Owe
Nam Le of CS Hyldcr E"' Lj.t CSL Type(,cc hrluw) (.{
a I RDResoldknnal
De---------
Address
q 7 V)e 0-V'1 �n' ricted u to)S,IXN)Cu. F.
/ 3 R l't?l�✓A 5 ted IAt2 Farad DwelLn
SigrTawr .�/ i �g� tal Roofin CovermTelephone t` tial Sohd Fuel gumm A Iiancc Installation
7� `f�SS �3ZZ nalDemolition
5.2 Registered Home Improvement Contractor(HIC)t /2�s $�8
HIC Company Name or HIC Regtstrant.N�rtt�r S /r Registration Number
Address Ybc6 /3 Z � Expiration Date
Signarcm 6, Telephone
SECTION 6: ORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... 0 No..... .....O
SECTION 7e:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR
OR CONTRACTOR APPLIES FOR BUILDING PERMIT
!T►, 601e 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.
signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
[�that
as Owner or Authorized Agent hereby declare
the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
lf. ^ ^•NameHture of Owner or Authorized Agent / to
ed under the sins and nalties of ru (�
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 H&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 I IO.R6 and I 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
Tvpe of heating system Number of decks/porches
Ts pe of cooling system Enclosed Open
3 "Total Project Square Footage"may he suhstimred for 'Total Proicct Cost"
TO THE BUILDING INSPECTOR:
Please be advised that as the owner of record I hereby give approval for the
following individual to make application for a building permit at the below
named premises: WOODY'S HOME IMPROVEMENT
9' t. PLEASANT ST.
Name of Contractor/Agent: I 1 W WENHAM, MA 01984
t�
Address of Project: l Lf� 1
Signature of Owner... .WIXI...... ...... ... ..... ... ... ... ... ...... ...
Date... ... .. �. ... .. . .. ... ...... ...... ... ... ... ... ...
CITY OF S.1I.E.-,I, 1LkSSACHL;SETI'S
B1:II.DING DEPARTMENT
120 WASHINGTON STREET, Yo FLOOR
TEL (978) 745-959S
Rim(978) 740.9846
lV\[BERRY DRISCOLL THomtS ST.PIEm
MAYOR
DIRECTOR OF PLgLIC PROPERTY/gl'B.DLVG COSL\pSS10NER
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electr(clans/Plumbers
Annllcant Information Please Print Legibly
Naine (ilusir organiratiomindtvydu:d): V� tg } /l e POLUrfP_lu2r✓
Address: / �2 Z2&S ai St
City/StatdZip: ���6 1w, i �11i4 afpl Phone M. q'7E- YG?�
Are y employer'Cheek the appropriate box. IType of project(required):
1.0 1 am a employer with 4. 1 am a general contractor and I
employees(full and/or part-time)." have hired the sub.contrecron 6. ❑New construction
2.0 1 am a sole proprietor or partner- listed on the attached sheet 7• ❑Remodeling
ship and have no employees These sub-contraeton have it. ❑ Demolition
working for the in any capacity. workera'comp.instargelm 9. 0 Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
rtyulred.i officers have exercised their3. 1 am a homeowner doing all work right of exemption per MGL 1 1.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152.41(4),and we have no 12.0 Roof repairs
insurance required.l t employees. [No workers' 13.0 Olha
comp. insurance required.]
'Any applicam Ih/cllooka hot II mud/AN ran out ON Unties bclew allowing limit walkela'COnlit"lladont pllliey inWmudoa
'I I.Imeuwrlen who subanit this adltlavit indicating lhey am doing all work and than him ounide conitnaCtola neap suhmb a new alfldavit irdics iln suck
:C.niimlors Ask cheek Ibis too mud anachod an aJdiliwd alma showing the porno of ttr su►cams laoni will their wuAnm'camp.putiry iafpm saM.
f am an employer that fr providing workers'rompensadon lnraroaeefor my employees. Brow is the pw1ey and fob slle
inforneadon.
Insurance Company Name: Rt� 2Ttcnc+
Policy lY or Self•ins. Lie. p:/ 4L f�C �U 6 Y(I Expiration Date:
Job Site Address: u /" '-d 4L Je City/StatNZip:�4,,, Mt f el�7K
.\ttack a copy of the workers'compensation policy deebratloa page(showing the policy number and espintloa date).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fig
of up to S250.00 a day against the violator. le advindxl that a copy of this statement may be forwarded to the Office of
Invcnitgations oroic DIA for insurance coverage verification. _
f do hereby errs under the pains and penaties ojperJary that the in/ormo cam provided above is true and marred
Ofa•ial use only. Do not write in this area, to be cunnpleted by city or town n/ffriaL
City or ruwn: __ Permit/l.lccnse N__.
i
!.suing Aulhurily (circle une):
I. Board of Ilealth 2. Ruildinu Department 3. City/town Clerk 4. Electrical Inspector 5. Plumbing Impeetor
6.01 her
CuoUct Person: _ -- -- Phone it:
Of CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
i I'J Ik NI h.l'!-KIN -;I I.
M 120 WASI IIXG'IONS-fit LET ♦SA F.M. MASiN( I It 'I I'I S'J1`I
T'rl:978-745 9395 • t'A3:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit k - -
is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(name of hauler)'
The debris will be disposed(of_in
(name of faci ity)
(address of facility) -
signal a of permit applicant
9 — z
date
Massachusetts Repartment of Public Safety
Board of Building; Regulations;tnd'Staddards
Construction Supervisor License.
License: CS 8829 Restricted to: 00 M� 11-
PHILIP A BLANCHETTE93R PLEASANT STREET
WENHAM, MA o1984"•
Expiration: 9/15=11
('onnniceiuner Tr#: 2179
A,,,.
B�'�o mr og oatfo5esu o o �
Constructlopsupenlsor Lkantw. , S
? License: CS 8829
t Blrtpda�67 .
9/15I1952 }.
1 ,16/2009e ' Trl�489M
PHILIPA BLANCfi@TT
93R PLEASANT
WENHAM;MA 019 Commimlouer,
.r