1-11 LONGFELLOW LN - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7th edition OFSALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
Tfiig Section For:Offibial-Use:Only
"�
er v
111ng
"Pennit Date Applied pp tet
Signature.'
j Building qofntfiiss:i6nW:lnspect6tofBii'Idings i Date.
,
SECTION
ECT N E:SITE,INFORMATION.-:
1.1 Property Addres 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(sit ft) Frontage(11)
1.5 Building Setbacks(1t)
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 0 Private 0 Zone: Outside Flood Zone?
Check if yesO Municipal 0 On site disposal system 0
SECTION 2; PROPERTY OWNERSHIP:
2.1 Owner'of Record:
T d Ave , s,,[o" lAN ni ic
for Se
a��7L 20o_:�
Signature
SECTION 3- DESCRIPTION OF PROPOSED ORK2,febeck'all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied 0 Repairs(s) W/1 Alteration(s) 0 Addition 0
Demolition 0 1 Accessory Bldg. 0 Number of Units— I Other 0 Specify:
Brief Des f Proposed Work': —sT ,r� ,
=O.
SECTION:4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
ITicial Use 0..n!y
(Labor and Materials)
1. Building $ 4. Building Permit Fee:$ 'Indicate how fee is determined'
2. Electrical 0 Standard City/t6vvn�Applicaticm Fee
$ 6 ToroJect'ial P Cost (Item 6)_k multiplier�tiplier ,x
3. Plumbing
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) Total All P $
Fees:
Check No. Check Ainownt::" Cash Amount:.
6. Total Project Cost: $ ,s 5 [:] Out tanding Balance Due:'
SECTION 5:. CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
T pn CS SL IIZR� 12 - 14 - fl .
S IAYsOS Ma ofsxgy/c. S License Number Expiration Date
Name of CSL-Holder _
1/ wi ��n S/ `p m fl List CSL Type(see below)
AddressT Descri lion, - '-
U Unrestricted((up to 35,000 Cu.Ft.
Signature R Restricted 1&2 FamilyDwelling
M Masonry Only
?!�"�87 • ��� 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)
" Lrn' e nr� �T, 4�e�\ee'e CO Inc 15432t5
HIC C�tmpany Name or H Registrant Name Registration Number
II Lyr:/snr sty snlp AIA [')IQ7(-) 2 -27 - !l
Address
yl�_ ] •�87(� Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION'INSURANCE'AFFIDAVIT(M:G.L:c. 152.§ 25Q6)),
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
1. 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::OWNER' OR AUTHORIZED AGENT DE
CLARATION> .
h AL i0 'L P&.42Pl1Y Sec J i CPS 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. M
Sj� Vrc�S � L7Tsov/.;c
Print Name
G -z3 . lt7
ature o wner Authorized Agent Date
(Si ned under the ains and enalties of r'u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I I0.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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 Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
40 www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): AL� y1Q �fc�n�rTY ScZcyice C
Address: l I jxr;is ro srt
City/State/Zip: .� .la M a @���1 ID Phone #: 21Y-8Y7 - 5 3-10
A,r�e,(�'ou an employer? Check the appropriate box: Type of project(required):
1.I rJ I am a employer with 30 4. ❑ I am a general contractor and I 6. ❑New construction
I employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp, c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.0 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.'
tConhwtors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. qq��
Insurance Company Name: 3f_i Go In P u Tbtca l /ns (fo
Policy#or Self ins.Lie.#: �Cl i.9 n FZ Expiration Date: 03 / /G//1
Job Site Address: one,-4$!/a,,,, 4,4 City/State/Zip: Sa `a.4 �/(�1170
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 certify under the pains and penalties of perjury that the information provided above is true and correct
Sienature• Date: - 23 -/O
Phone#: 9&.- 99-1 .- 5970
Ojftcial 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#:
RP, A La010 0)' 0: 05 Ooorley Agency (FRX)COl 886 9622 P. 001/001
ccoR :CERTIFICATE OF LIABILITY INSURANCE OPID ►
ALBIlIT-1 04 ld 10
THIS CERTIFICATE LS ISSUED AS A MATTER OF INFORMATION
ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE
�, 19eaa7f HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR
Doorl Inc.
17�Si:xthi�A'Lrenve ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Itast3,IGzaeiiTrich;RI 02818
Fihones 6Ql"8,8'6 ,9,600 Fax:401-886-9622 INSURERS AFFORDING COVERAGE NAIC9
INW a RA Beacon Mutual Ins Cc
INSURDR 0: _.
AyPPine ?r rty Services, Inc. INBURERa
l geeklaa Caso axy Rd Box 446
i $oitvate RI 02857 INSURER Ot
INSURER E:
;TNEPOLICAFIII,p�WIIRANCEII.SIEO BELOW HAVE OWN ISSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INOICATEO.N01 WMWANMNS
:AMrREO(♦)pEF ff}`yTERMOq.001'�RpN OF ANY CONTRACTOR DTHFR DOCUMENT WITH RDSMOTTO WHICH THIS CERnFlGTE MAY BE ISSUED OR
:WY,� NN LEI EJp6tXHANWAFFOROSo BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERM$EXCLUSIONS AND CONOmONS OFSUCH
;PABQpE WTE LMITSBHDWN M11Y HAVE BEEN REDUCED BY PAID CLAIMS.
eeiunuRANeE POLICY NUMBER o )Df YYV MMX oATl6 ilAwL7��oN UMYB
EACH OCCURRENCE i
a 100 �QOfIfi,RAL W040•r PRM P F. 2
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Affi � At� E�et L- YIN 59000 03/16/10 03/16/11 ox.EAc"AmDENr S S00 000
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RI •� NBkaror 'FL DISEASE-POLICY LIMIT 3500 .000
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SHOULD ANY OF THEAEOVE PESCIaeEO POLICIES EE CANOELLW 13EFOMTME EXPIRATION
RICONTR PATS THEREOP,THE ISSUINO INSURER WILL ENDEAVOR TO MAL 10 OAYSWRRYEN
NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT.BUT►AIRRE TO OD BO SHALL
Coo otors' Registratioa IMPOSE NO OBLIGATION OR ULBILRYOPANY MINO UPON THE INSURER•ISAGUMOR
y .iceas`aag Board
ROPPAMETATPJM .
-' dea¢eRl 02908 AumoRraEo A
426 r :;kw�
CORPORATION. All rights rasorvod.
Tho ACORD namo and logo are reglstarad marks of ACORD•
,
Ptaseachuscrn- Dcpmlmcnr ar Public Surer --
Bmtrtl nl'Building Rcwlationx and Snuul:u•xls !Construction Supervisor Specialty License
License or registration valid forindividul use only
License: CS SL 101003 1lrefore-thu-expiration date. If found return to:
Restricted to RF,WS " - Board of Building Regulations and Standards
Gne Ashburton Place Rm 1301
STAVROS NIOUTSOULAS Boston
11 WILSONSTREET .,,.
- - SALEM, MA d1970
---.�"� Expiration:f'ummixiimer lytgrkll I Not without sig
nature '
Tr#: 101003'
- Bpa� 0 ul 611lg�gllio ns aII tall ar
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home ImprovemeiYk_Contractor Registration
- - Registration: 154326
Type: Private Corporation
Expiration: 2/27/2011 Trrf 279845
ALPINE PROPERTY SERVICES'd0=j
STARROS MOUTSOULAS
11 WILSON STREET =_= - •`.'
SALEM, MA 01970
Update Address and return card.Mark reason for chsnge-
• ❑ Address Renewal Employment Lost Card
npacnt o 501+ml07-eCe4007
fo BuildiagRegu 'dos and Sm de License or registration valid for individul use only
Bo ;
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Regist4lon. 154326 One Ashburton Place Rin 1301 ,
Ex I tiorr•.-2I272011 Tr# 279846 Boston,Ma.02108
was
ALPINE PROPH, EES:CO,INC.
11 WILSON STREf y' . . 1. `"'—" Not valid without signature
SALEM,MA 01970 "• • Administrator _