124 MARLBOROUGH RD - BUILDING INSPECTION 1 r The Commonwealth of Massachusetts
/ 1 Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Denta
One-or Two-Family Dwelling
This Section For Qfftud Use Only
Building Permit Number: afe Applied:
/Building Official(Print Name) S Dad
a
SECTION 1:SITE INFORNfATION
1.1 Pcr�operty Address: ^ /J 1.2 Assesso s Ma P 1 Numbers
t�7 Ma rLZfO✓S4 041
L 1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA 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 Requred 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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Ree�r,d: �/ •ram ' _ ��O l�(Zi.�
�oLI ft. I)n�2r �1�121FR/ S (gym 1�1f>
Name(Print) City,State,ZIP
rn,,r WeicJ�, Q7V s9y-Of/V / /z Si54 ® 4.0G.Co
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED ORK=(check all that apply)
New Construction el Existing Building Owner-Occupied trl Repaits(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
BriefDc ' tionofPr osedWorkz: vnO�!L 2
V 4
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
1.Building $ 1. Building Permit Fee:$ Indicate how fee is detemuned:
2.Electrical $ ❑Standard City/rown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
1 -2
6.Total Project Cost: $ — Check No. Check Amount: Cash Amount:_
0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor L'cense(CSL)
License Number Expiration Date
Name of CSL Hal de
List CSL Type(see below)
No.and Street Type .Description
U Unrestricted(Buildings up to 35,000 cu.R
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances .
I Insulation
Telephone Email address D Demolition
5.i stered Home Improvement C)
1/..•u,' -� � � G I t W(' HIC Registration Number xpirati n Date
HIC Company ant Name y GG
. et C
and Street S� C Email address
o owB q-) Q( i
City/Town,State,ZIP 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 WREN
OWNER'S AGENT OR CONTRACTOR 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.
COE °I, zkz�-
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 or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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 can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Namber 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"maybe substituted for"Total Project Cost"
THE Policy Number: MPS0899G
MAIN
TREET
AMERICA ,
GROUP BUSINESSOWNERS COMMON DECLARATIONS
MAIN STREET AMERICA ASSURANCE COMPANY
4601 TOUCHTON ROAD EAST,SUITE 3400,JACKSONVILLE,FL 32245-6000
Item 1. Named Insured and Mailing Address Agent Name and Address
KTJ CARPENTRY AND HOME THOMAS GREGORY ASSOC INS AGCY
(SEE NAMED INSURED ENDT)
1 MURRAY CT 601 EDGEWATER DR STE 235
GROVELAND MA 01834-1551 WAKEFIELD, MA 01880
Agent Phone No. (781) 914-1000
Agent No. 200443
Item2. Policy Period From: 03-26-2011 To: 03-26-2012
at 12:01 A.M., Standard Time at your mailing address shown above.
Item3. Form of Business: INDIVIDUAL
Item 4. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to
provide the insurance as stated in this policy.
This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown,
there is no coverage. This premium may be subject to adjustment.
COVERAGE PREMIUM
Section I —Property $ 208 . 00
Section II —Liability $ 1, 233 . 00
Inland Marine $ 175 . 00
Total Policy Premium: $ 1, 616 . 00
For Coverages subject to premium audit: Annual Audit Applies
Item 5. Form(s) and Endorsement(s) made a part of this policy at time of issue:
See Schedule of Forms and Endorsements
u
Countersigned:
Date: By. F ,-
Authorize Rep esentative
THIS BUSINESSOWNERS COMMON DECLARATIONS AND SUPPLEMENTAL DECLARATION(S), TOGETHER WITH
SECTION III —COMMON POLICY CONDITIONS, COVERAGE PARTS, COVERAGE FORMS AND ENDORSEMENTS,
IF ANY, COMPLETE THE ABOVE NUMBERED POLICY.
BPM D 1 1207
INSURED COPY
x.-
CITY of S.0 Nfj AISSACHUSETrS
9LtI�LYG DEP.Ilt-nuuiT
120 WASHLNGTON STRM, Ye FtOOIt
TIEL (978) 74S.9595
KIAMERtEY ORMOLL FAX 740-9846
MAYOIt DHO.+W ST.REruts
D IRECTO R OP PC BLIC PROPERTY/K aMLNG COWUSSION ER
Construction Debris Disposal Attldavit
(required for all demolition and renovation work)
In accordance with Debris, and the provisions of MOL c 40, S 54;
the sixth edition of the State Building Code, 180 CMR section 111.5
Building Permit p
is issued wit
h the condition 11 work shall be
1
l 1, S I SOA. disposed of in a property licensed waste disposal fac lity as defincd bytMGLng oe
The debris will be transportcd by:
(name of hauler)
The debris will be disposed of in
ro?� S,LCe r 1, _
(name oY foci )
Ij1dress of facility)
siynanue orpermit applicant
13 —'1K
dife
I.hnw(I•�
CITY OF S.UY.Nf
PUBLIC PROPERTY
DEPARTMENT
Iflf�• �y�,ry1
MAYOa I b WA9Ytwm fts=•&AL/M M&nAcHLsarts t111'e
M 9'8•715.95"•FAi.975-7W9Me
HOMEOWNER LICENSS EXE.NPTION
Pfeaw Frint
Date q- / J q-61
JOh Location I a YYl Q r L�ere -o v S 4 /Zf
Home Owner Addreq la`( l n a r k a r o 4 t, (�
Home Owner Telephone ?Y S-r Y o 4/
Preaeot Mailin/Addrer s+} 2 e
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lea and to allow sub homeowners to engage an individual for
hire who,does not possess a licarae,provided that the owner acts as supervisor,
DEF NMON OF HOMEOWNER
Person(s)wbo owma a parcel of Lod on which he/she raids or intends to reside. on
which there is, or is intended to be,a one or two family dwelling attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"haneowne "shall submit to the Building 0®ci4 on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The underaigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply with said procedures and requirements.
H0MEOWNERS S[GYATL'RE � /
APPROVAL OF SUILDLVG NSPECTOR
See other side for state code