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4 LILLIAN RD - BUILDING INSPECTION 0 The Commonwealth of b[assachusetts ,? Ein Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 730 CMR SALEM df Revised tLlar 2011g Permit Application To Construct, Repair, Renovate Or Demolish aOne- or Tivo-Family Divellingis Section ForOfficial Use Only bedntName) .ignature - 1te SECTION I:SITE INFORtYWTION 1.1 Property Address: i dy 1.2 Assessors Map& Parcel Numbers 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 OWNERSHIPIr 2.1 Owner'of R cord: Name(Print) City,State,ZIP No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction ❑ I Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) in Addition ❑ Demolition ❑ Accessary Bldg. ❑ . I Number of Units_ Other ❑ Specify: Brief Description of Proposed Nork': `c-` - SECTION 4: ESTIMATED CONSTRUCTION COSTS- Estimated Costs: Item Official Use Only Labor and i`.larerials 1. Building $ 2? O I. Building Permit Fee: S Indicate how fee is determined: �. F:Ixtrieal $ 3-�U a Cl:Standard e CityiTownApplication Fe ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing S (1 v ?, Other Fees: 3 I. Mechanical (EIVAC) S List: i. \ "Ironical (Fire S 5n? ression) Total All Fees: S �, Check No. Check Amount:- Cash Amount: -total Pro Cost, s z8 l ❑ Paid in Full ❑ Outstanding Balance Dui Xle-t 7 4o A er SECTION 5: CONS'rRUCrION SERVICES 5.1 C�otutruetion Supervisor Licetue(CSL) as S ! ` License Number E.cplra Inn Date Name of CSL I/!olde�r G (� / —Z {—�-v 6� y(� List CSL Typo(see below) 'i'ype - Description No. and Street U Unrestricted(Buildings up to 35,000 cu. 11. .� R Restricted 1.4e2 Family Dwellingr City/,rown, State,LIP NI Nlasonr RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation rele hone Email address I D Demolition 5.2 Registered Home Improvprttent Contractor(II[C) I-I[C Registration Number Esp ration Date I IIC Com it Name ur i R Re istran�Jvame Nyd Stree ;^„ _ �g, g3 7 5_�, Email address .1 City/Town, State, ZIP e 14 -Z U 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, as Owner of the subject property,hereby authorize J---I &-A,' to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW 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 ur Audwrized:4;ent's Nome(Elecnunic Signature) Date NOTES: I. ;\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under NI.O.L. c. 112A. Other important information on the H[C Program can be found at www.lnass. uv oca Information on the Construction Supervisor License can be found at www,ntass.-,ov dL 2 \Vhen substantial work is planned, provide the information below; Total floor area(sq. tt.) _(including garage, finished basement/attics, decks or porch) (boss living area(sq. tt.l — _ Habitable room count Number of fir cplaecs._. Number of bedrooms -- ----__—_-- Number of bathrooms Number of halt baths —_---- _ Number of Type of hooting system _ decks/porches-- -- — -- Il Pe of'cooling syslent -- Enclosed --- Opcn _ ----------- }- l otal ProleCt Squ.11e Footage' tuay be sllbitihltild (i)r"Iot.d Project Cost" n yF CITY OF &UE, ,I, %LNSSACHUS=S s ' BUILDING DEP.1R LENT ' y 120 WASHINIGTON STREET, 31 FLOOR T EL (978) 745-9595 F.ue(978) 740-9844 KI.,,fBEnEY DRISCOLL MAYOR "I1-IOM.�S ST.PtE.aRB DIRECTOR OF PUBLIC PROPERTY/BUILDING CONL�IISSIONER Workers' Compensation insurance AMdrvit: Builders/Contractors/Electricians/Plumbers A i rlicant information - Please Print Legibly Name(0usitici&Organiraiorulndividuul): Address: /l o(ut, P4,t,, city/state/zip:� /� t�L 1414 Phone hl: OY 4 72' - S L( Are you an employer.'Check the appropriate boas Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and! employees(full and/or part-lime).• have hired the sub-contractors 7. Q New construction 2.Wi nin a sole proprietor at partner- listed on the attached.sheet t • ❑Remodeling ship and have no employees These sub-contractors have V. ❑Demolition working for me in any capacity. workers'camp.Insurance. 9, Q Building addition (No workers'comp.insurance 5. Q We are a corporation and its required.) officers have exercised theft 10.❑Electrical repairs or additions 3,Q I am a homeowner doing all work right of exemption per MGL 1 I.Q Plumbing repairs or additions myself.(No workers'camp. C. 152,41(4),and we have no 11.❑Roof repairs insurance required.)t employees.(No workers' I).Q Other camp.insurance required.) •My Applicant that vina;ke box 01 must aim nil out the u<lim balow showing chair workers'eompenudua puney infurmalion r ILvnauwm"who submit this affidavit indieaing thcy am doing oil workud thee hit uuttidr cfinlmctar must submit a now aMdavil indicating such. :Cunimaton that check this box must attached an addidund,barn showing the name of the sue.•oninear and theft worker'sump.policy ini;,n adoa. !sun an employer that Is providing ivorkers'compruradors lnraraner jar my employers. Below Is thr polley and fah s•/q ins/orrnutlan. Insurance Company Name,. Puficy a or Self-its. Lic.4: Expiration Data: Job Siie Addruss: City/State/Zip, ."tach a copy of the Ivorliers'compensation policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Suction 2$A of MGL c. 152 can lead to the imposition of criminal penalties of s tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a fine of up to$230.110 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Oft ice of Invesligutiuts of the DIA for insunnca coverage verification. /du lrvrrby r iter r rr n r prnulll u/perjury that the Lr�unnuNoa providaJ ubt yr is rra lid currrrL 1:n uuy���.�j �.. Dot • �/` / 3 v v phone* ------------------- U/Jirial use duly. Ou nut writr in 1/111 urei4 to be completed by city ur town n/livial I i city or Town: __ _ PcrmlN.lcema# Issuing Aulhority(circle one): - 1. Ruurd of i(cuith f. Iluibling ❑eparnnmtt I.Cityffown Clerk 4. Electrical laspectur 5. Plumbing inspector 6.Other Contact I'crtnn: Phone I/: r CITY OF SAIL E-M2 INLASSACHUSETTS ©t:[LONG DEPARTMIUNT 1�0 CS/.15HLNGTON STREET 31°��..' FLOOR TEL (978) 745-9595 ;<! [3ERI EY DRISCOLL F-LX(978) 740-9346 ,`,LkYO:t TH01Ns ST.PIERIIs DIRECTOR OF Pt;DLIC PROPERTY/81:tLDLYG CONNIJSIO iER Construction Debris Disposal Afttdavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section 11 1.5 Debris, and the provisions of NfGL c 40, S 54; Building Permit tt is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by bIGL e 111, S 150A. The debris will be transported by: qt7— (nume of haulur) I'h/ef d ebris will be disposedof in (name of facility) se�6c (address or'facility) signature ufperntit applicant l� � 3 date i�