20 LINDEN AVE - BUILDING INSPECTION (2) The Commonwealth of Mass;CMIR.
tts
Town of
Board of Building Regulations andards
`- � Mjssachuscits Slate Building Code. 79 7'"edition BuilJmg Dept
KUMMMOM
Building Permit Application To Construct. Repaovate Or Demolish atlOne- or Tiro-Fuinsl DiveThis Section For ORcianlutWing Permit Nu cDate Ap l
Signature: 'I
Build mmissioner/Inspector of Buildings Date T
SECTION 1:SITE INFORMATION
1.1 PrTety Address: 1.2 Assessors Map i Panel Numbers
M
I.la Is this an acc ted sirecO yes no
Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(fl)
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.46.154) 1.7 Flood Zone Informatlos: 1.8 Sewage Disposal System:
Zons: _ Outside Flood Zonal Municipal O On site disposal system 0
Public O Private O Cheek if a0
SECTION 2: PROPERTY OWNERSNIP..tIl
2.1 Owner'of Record:
Name IPrinq Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O Repsirs(s) O Alteration(a) O Addition O
Demolition O 1Accessory Bldg.O 1 Number of Units_ Other O Specify:
Brief Description of Proposed Work
SECTION•: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMCI&I Use Only
hem I Labor and Materials
1. Building f 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)x multiplier x
) Plumbing f 2. Other Fees: 11
1, Mechanical IHVAC) S List:
s Mechanical iFire S J/S�jU Total All Fees: S
Su resaion
Check .No. _Check Amount: Cash Amount:_
6 Total Project Cost S 0 Paid in Full O Ouwanding Balance Due'
0\0,d J6 �O'��e ck,(
SECTIONS: CONSTRUCTION SERVICES r
!.1 Licensed Construction Supenisor ICSL) 1_/2lyl q
1;e- Zr!O A.",rG //- License Number E spuar on II
Ntrac of CSL Ifgkkr /r✓ QdlLi II C'SL Type I see below)
(o/C1 �o iT<i� asil9cf�A.�
AJJres� Ti, Description
U I Unrestricted(up to 35.000 Cu. Fr
R Restricted Ih2 Family Dwelling
Srsnarwe M Masonry Only
RC Residential Roofing Covering
Telephone W S Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered He Improvemeat Contractor INIC) Y6S
HIC Company Name or HIC Registrant Name /n Registration Number
G/lJ .So � u
AddRisI
/GS Fr•�//
Espinrswn ate
Signature T Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 1I 2SC(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? YesI 7T� No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 1 2 c -�vsrs zv�P as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this buildingpermil application.
Dam
Si aNR of OwrieF a —rr
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, T6 ne C/ ,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.
Print Namur//
Signature of Owner or Authorized Agent Date
Sr ned under the pains and penalties of
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor I HIC)Program), will S&have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. 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.RJ, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) lincluding garage, finished basement/attics.decks or porch)
Gross living area(Sq. Fr.) Habitable room count
:Number of fireplaces Vumber of bedrooms
Number of bathrooms Number of half.baths
Type of heating system - Number of decker porches
Type of cooling system Enclosed . Open
1 "Tool Project Syuare Footage"may he,uhsrimted for 'Total Project Cost"
CITY OF S.ULE.N1, �tLkSSACHUSETTS
' Bl.'IIDLNG DEPARTtENT
120 WASHLNGTON STREET, )so FLOOR
7� 9 TM (97>� 5-95 S
F.,Lx(978) 7449&M
KINBFef FY ORISCOLL
T
HAYOt }sostAs ST.PtFRr!Is
DIRECTOR OF PUBLIC PROPERTY/BL'DDLNG CO.'LN(1SSIONER
Workers' Compensation Insurance Aflidavit: Builders/Contractors/Electrielans/Plumbers
-knnllcant Information �JPl�ease Print Legibly
Naine iBusinc> 0rpyurarionlnhv,dmdl: �Ir2 ��it/is/E>ri/ O/�'GI C1�11���p (/i.VcZ C
Address: 5?i�F,41, 671/A�PG a~ S T—
City/StatclZip: XQ t4G�a.a vvefss Phone/P.-
Are you as employer'Cheek the appropriate boa: Type of project(required)•
1.0 I am a employer with .2-- e. 0 1 am a general contrwcror and 1 6. 0 New construction
employees(full and/or part-time).• have hired the su&contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet : 7. ❑Remodeling
;hip and have no employees These subcontractors have S. 0 Demolition
workingrot me in an capacity. workers'comp.insurenci
Y Pn tY• 9. 0 Building addition
required.]
workers'comp. insurance S. ❑ We are a corhave
exercised
and its 10.0 Electrical repairs or additions
required.] ot7it:as have areteiaed their
3.0 1 am a homeownar doing ail work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,f 10),and we have no 12.0 Roof repairs
insurance required.) t employcca. (No workers' 17.0 Other
comp. insurance requirad.)
•Any applicant tld chodu ties el mast also ma ttta the Mlia babe ahrwiag theft rorke"cattpetteaafon policy infumalWtf_
'I t.vraownas who suhwte this aAl6vis indicoins rttry as doing all work ad tha him ou"idt eanttei:tas mttet rhrk a new a1tISvG indidiq rook
=C..tttroL that chock this bm mug avached an 3"imi al dwat showing the tote,of line wtheeNeaator ad th*worker'corny.policy iaronnio aa.
/as an enip/oytr ihau is providing•workers'rompenraaloa Injurotra for tgy taeplayees, St/ow/s the policy on4fM site
Insurance Company Name: crr 2_zltf u�
Policy N ur Self-ina. Lie. N: Expiration Date: «�O
!ubSireAddress: of City/Statelzip: Sa41e� A&rv.s'_r
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
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to $250.00 a day against the violator. Ile adviwd that a copy of this statement maybe forwarded to the Office of
I nvcstt gal iutu of the DIA for insurance coverage verification.
/do hereby certify urrder aka pains and pens/der of perjury that the information provided above is true and rants
Doran
Official use only. Oo nor write in this area,to be:ump/tte✓by city or torve r./f)a'ial
City or ruwn: __ Prrmir/LlccnseN__. ..
Issuing.%ulhority (circle une):
I. Ituard of llealth 2. Ruilding Department J. Ciiytrown Clerk ♦. Electrical Dnspecto► 5. Plumbing Intpeetor
6. ther
luniact Perron:__ ._. _. Phone N:
CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
11`,1,-it I20\%'.\+III\G:iL`7$INEL'i0 $.\Ir\1,M.tNi.\l
'fGl:Y78-7� 9iy$ f:\X:978-7449846
Construction Debris Disposal Affidavit
(required I'or all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CIVIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit q 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 fau Ity) -
(address of facility)
Signature of permit applicant
due
r • • Page No. Of Pages
;TOM O'CONNELL
'DBA BRADFORD VINYL
610 S. Main Street
s, Bradford, MA 01835
Phone(978) 372.3764
PROPOSAL SUBMITTED TO PHONE DATE '
STREET - JOBNAME
/{
CITY,STATE and ZIP CODE Kx JOB LOCATION
S44 S
ARCHITECT f DATE OF PLANS { JOB PHONE
4
We hereby submit specifications and estimates for:
/?go '4�cjj r r A r! o /ems s ev" �s ! S ee":2 a�
l2Gc,
tt f�
S 7`'v!/ /'Y C cu Jv z� C 40 i._7 E> cis
w s %w/ rLr Pcrr G s9 se ' cl�GS 2 /2c 0 14' .: 5 S G/r 4-37 e'�f TO eeiii .
�Poaf /9 A,_cr eN c/l 3 19'. �Z .2cro
�z- uroyr s9�/ T d e�L.e-l�ry� !" T`2sls'�F
We Propose hereby to furnish material and labor— complete
in accordance with above specifications, for the sum of:
L / v'Y 7'6/i>el S-9f ✓Yr v s- dollars($G�� ).
Payment to be made as follows:
0�,
10,
e!-
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized
manner according to standard practices. Any alteration or deviation from above specifications Signature
involving extra costs will be executed only upon written orders, and will become an ezira
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control Owner to carry fire, tornado and other necessary insurance. Our Note:This proposal may be
workers are fully covered by Workman's Compensation Insurance. v withdrawn by us if not accepted within J days.
Acceptance of Proposal —The above prices,specifications �� ��(�
and conditions are satisfactory and are hereby accepted.You are authorized to do the SignatureLGC-�d'
work as specified.Payment will be made as outlined above.
' �G
Date of Acceptance: Signature