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112 MARGIN ST - BUILDING INSPECTION (2) _ --- I he C'omnwmcialth ul'b1us,;lrhusclts Iyo.Ird of Madding Regulations and Stand;trJs CI VY OF tr \fassachusclfs Slats Building Cudc.'78B('hIR s.\Lli\I Building Permit Application To ConstrLICI. Repair, Renovate Or Denitllish a R✓ri.Icd I/Ile Urte- or rirn-Piunrlt LILL411 Phis Section For ORicial Use Building Permit Number: It, led' --- BuJJmy QI)inul(Prinl shune) yllat Uale SECTION 1: SITE ATION 1.1 Pr 41 WJress: L 1.2 essoi Iap s Parcel Numbers I.la Is IM an acce ted street? 'a no Klan Nunlher Parcel Nwnhcr _ 1.3 Zoning Information:n 1.4 Property Dlmenslonss /.uniny District I'n�pllrceJ taw Lul An:u Is III 4 1.1 BuIIJInO Setbacks(R) Fmn luye(II) Front Yard Situ Yanle RequiredI'rvviJed RequiredProvided Reyuind Rear YardI'roviJeJ 1.6 lvahr Supply-IM.G.1.V. JU.§JJ) 1.7 Flood Zone Informatlont In Sewayt Dlaposal Systems I'ublle Prirma❑ Zone: _ Outsidt Flood Lunt? Chock If es($i Municlpd n site disposal s)rwrn O SECTfON7: PROPERTYOWNERSHIPt >.1 Owntrt of ReeordI �GivrC / fei[u/c�o c 4(� S NIII nu(Print► (try,�IJIa.l.IP �-7vr - Y N6 Nu.,Ind Street fele hunt p hmaJ AJdross SECTION): DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existilly Buildiny O Owner'Occupied O Rep III III In:ls) 111 Alterotlon(s) ❑ Addition ❑ Demolition ❑ Accnsory Bldy.❑ Number of Units Brief Description of Proposed \Vark-: Z' d-f I Other ❑ .Speciry; �Z-� 1 /-cluo �f/ C SECTION 4: ESTIMATED CONSTRICTION COSTS Item Estin a cd Costs: 1 L.Ihur and.\I:neriab) Official Use Only 1 Building S 1. Buildiny Permit Fee: S Indicate how lee is determined: `. FI"irical S ❑Standard City:Tuwn Application Fee t I I'(Iunhiily S ❑Total Pruject(-ustl IMere'6)x multiplier `. UlherFeas: S J. \IV01.ulii.11 III\ WI S List: \Icdl.wi.ul ilhre —_--.-- Cu 'rr :iun1 S final .\II Free: $_ — 1'nlul Project Curt i�sQU�r w ChccA 11'" .lnpnnrt: _ l'.i�h \nenun: ❑P.tiJ in Full (]Outst:wJiny Hdl.mce Due: serru)N s: r(1N FR11 "I'lON -S"i lC FS t,l Cmulructimt Supen isur License((St.) �� `�1) (U .. I: iraian D:IIe I \,arse aj CSt. I to Kr - !1 'pC 'ar N,,. . f . mJ\heel - l hlrestndeJ I Duddin i Ii to 14,U111)al. Il.l Stamm led IS2 Tamil I)t+ellin \I \I;uun Cigil'ae n.Male./II' RC Ha,lin COW';n µ'S window-old SiJin - SF Solid fuel lluminy r\ppliances Iniulmion D 17cmolitimn f mail aJJre,s // � I'cic bona (!�S^��^ 5.2 Registered I�luma, Improvement Contractor IHIC) IIIC' Itcghu;uln Numhcr Ifspinei nl Daly I IIC CIM N ) N'm 'Or It4istru'll Nwmo Email address No. wt 5t�e Glv�� �o(J3 6�U �z ` l�aU — G\G� fete one Ci !Town,State ZIP SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. Il7. SSC( ) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this atlldavit will result in the denial of the Issuance of the building permit. Signed AtMdavit Attached? Yes .......... SECTION 7a:OWNER AUTHORIZATION TO BE C051PLETED NVHEN OWNER'S AGENT ORCONTRACTOR APPLIES FOR BUILDING PERMIT I, 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. Date I'riut Uwaur's Nwile(Electronic Signature) SECTION 7b:OWNERr 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 (� Mill Ihintl)wneisnr \uthotveJ,\guar +Nantu11kUn' llgnIlea) Non& rug 1 'o0\gIle registered in the a e In pruvanlenttCuntmctur(HIC) Programl.n illjn f`have access to hires an thearbitration slracwr p\og`aIs or guurnuylnlni under on the Conlsvuctiaa Supers iar Liceer important nse can be found at tion on the C Program c'antbelthwtJ at 2 \\'hen substantial tsork is planned, p.--the information below: I including garage. linished basement attics. Jerks or porch I rota( (lour area I,y. Il.l — Habitable room count -- - Gra;s lining area I sq. II.I .--... . .. __. . .. \uulher of hedrowns - . . . 1 \umher al lircplaccs _ - \anther of hall halhs \ulnbcrolhalhnwlns . . - \lunherofdecki' parches I)pe of hc.lrng i)'tem (t)yn I I'nclo'eJ I\I'e at epalllig N Qelll t "I Ial Iln,j�til square I'ool.lce" II1',1\ he"'I'fltltcd Il,r 'I\nal Project Ca,I" CITY OF SAI.EM, 1'LkSSACHLSEM Buit.DiNG DEP ART.MMNT 120 WASHINGTON STREET, 3"e FLOOR TFL (978) 745-9595 FAx(978)740-9846 Kl%fBFRt F.Y DWCOLI MAYORTHObtAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUI DLNG COSWISSIONElt Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Amilicant Information Please Print Legibly Naftle(BusiiwssOrganizatioMndii/vidual): S C Ocf ffiA,-),' � Address: 1�10��tLCXJ�4 City/State/Zip: 61 iA Phone #: ran 03 " 7,c J ` (CDC CD 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 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner. listed on the attached sheet.t 7• ©'modeling ship and have no employees These subcontractors have 8. ❑ Demolition working for me in any capacity, workers'comp. insurance. _ 9. El Building addition [No workers•'comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their I0.❑ Electrical.repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers'comp. C. 152,§1(4),and we have no 12. oof repairs insurance required.]t employees.[No workers' 13 ❑Other, COMP.insurance required.] •Any upplironl duo darks box aI must also,roil ouuhe soctiom below showing their worker'compensadon policy information. t I t.xmeow�ners who whmit this affidavit indicaing they are doing all work and then hire outside contractor most submit a new afltdavit indicating such. :comraetun that check this box must atnehadan additional sheet showing the name of the sub.:ontrdom and their worker'camp.puiiey information. I am an employer that Is providing workert'compensation insurance for my employees. Below Is fire policy and Job site inforinmion. �y� Insurance Company vane: 6fi/ �r t Policy#or Self-itu.Lie. #: Expiration Date: 6 l ! Sy6-u-Job Site Address: r/l� �'� flit .S�' CitylState/tip: 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. 152can lead to the imposition of criminal penalties of a tine 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 fine of up to$250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of Invostigutions of the DIA for insurance coverage verification. l do hereby certify corder rite pul and penalties of perjury that lire fnforrrrutlmr provided a ove is true and correct Skmat im // '7 /' �-7 Date: e-6y la Phone#: ( S - <7G Ste- it/'eP C Q Official use only. Do not write in this area,to be completed by city or Town offleirtt City or Town: Permitll.lcense# Issuing Authority(circle one): 1. Board of health 2.Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.O 1lter Contact Persml: Phone#: CITY OF S�U ENI, -NAxSSACHUSETI'S • BUILDIING DEPARTNSENT 130 WASHNGTON STREET, 3' FLOOR m ' TEL (978) 745-9595 FA.Y(978) 740-9846 KINtgFRT FY DRISCOLL 1 EY D THomAS ST.PIERRa DIRECTOR OF PUBLIC PROPERTY/BUILDl2NG COSLMISSIONER 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 # 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 MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in S C-,-q J (name of facility) s46e�' - (address of facility) - signature of permit applicant l l� ea Ate an „�ttdw Nlassachusetts- Department of Public S:d'etc Board of Building Regulations and Standards Construction Supervisor License License: CS 64210 N SCOTT T DAUTEUIL 7 APPALOOSA AVE y PELHAM, NH 03076 Expiration: 1/6/2013 ('onuuission"r Tr#: 9339 r `Office"D m r arcs i ass egu ala0.-. HOME IMPROVEMENT CONTRACTOR Registration 5118575 TYpe: . Expiration 4/3/2013 -DBA S - DAUTEUIL DEVEtOPMENIT SCOTT DAUTEUII:, �E _ I �.a 7 APPALOOSA AVE t PELHAM, NH 03076`%;ia�==s'--3 Undersecretary k