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175 MARLBOROUGH RD - BUILDING INSPECTION (3) !4rll ©rw The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR SALEbI Revised.b/ur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) ignalur Data SECTION 1:SITE INFORMATION 1.1 P` dra gY y%22�� ptT 1.2 Assessors iNlap&Parcel Numbers 1.1 a Is this an accepted street?yes_ no Ct Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(It) 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: LS Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTION2: PROPERTY OWNERSHIP' In m�e(Frio V n`xbou City State,ZIP \ D v* VA T�ft 159o-sb1)i No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) I$. I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Bri� scrS(igRotPropos 91" id\ ork�t 'S� �'� LzJ S SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) I. Building $ I. Building Permit Fee:$ Indicate how fee is determined: �. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: 4. `leeh;mical (HVAC) $ List: 5. i'dechanical (Fire $ Suppression) 'road All Fees:$ ` Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: $ \'aa` ❑ Paid in Full ❑Outstanding Balance Due: ✓��//L / v ��i 4e� SECTION 5: CONSTRUCTION SERVICES 5.1 Construction SupervisorrtLiceiise(CSL) CSS —\<),5 Q f License Number Expiration Date NameOfCSL Holder \I �l—�� List CSLType(see below) No'. and Street` Type. Description ' ©L &e5� �� C U Unrestricted(Buildings Up to 35,000 cu. ft.) R Restricted 1&217amily Dwelling Citylrown,State,ZIP (' ibl Masonry © k Roofing Covering W Window and Siding SF Solid Fuel Burning Appliances Jb lft o(kA Uev; I Insulation Tdc hone —� Emailaddress 5 D Demolition Q5..2 Registered Home Imor�ovg � niennt�Ccontractor(IIIC) r`"'�� C) FIIC Registration Number E.piratiun D;lue I ��mp.�yi)E.[ IC Reg'st:tlant N;uC o.aSlree Ct1t"�`��LM Email address 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...........❑ SECTION7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN: OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Dale SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my na a below, I hereby attest under the pains and penalties of perjury that all of the information c taitie in this ap ication is true a accurate to the best of my knowledge and understanding. Print Owner's or \ulhorized Agent's Name(Electronic Signature) Date 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 NLG.L.c. 142A.Other important information on the FIIC Program can be found at www.mass.,,ov'oca Information on the Construction Supervisor License can be found at www.mass.�av'de 2. When substantial work is planned,provide the information below: 'rotal floor area(sq. B.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. It.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches rype of cooling system Enclosed Open 3. "rotal Project Square Footage'may be substituted ror"'rota) Project Cost" 3 CITY OF SiU.EN I, N-LkSSACHUSETTS a BuILDING DEPARTMENT 120 WASHINGTON STREET, 3w FLOOR TEL (978) 745-9595 Ella(978) 740-9846 [BFRt F.Y DRISCOL MAYOR THonIAs Sr.PIE.aRs DIRECTOR OF PUBLIC PROPERTY/BUI DL`7G CONI]MISSIONER - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information r Please Print Legibly Niltne (13usinesOrganizalion,'Imhvicivail): }� � Address: City/State/Zip: "1f c Ctce �A "Oftone #: J Are you an employer?Check the appropriate box: 'type of project(required): I am a employer with t — 4. ❑ 1 am a general contractor and 1 6. New construction employees(full and/or part-time).° have hired the subcontractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7• Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9, ❑ 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 11.❑ Plumbing repairs or additions myself, (No workers' comp. c. 152, §](4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp.insurance required.] •Any applicant dirt ducks box#1 must also 6l1 cot the section helowAowing their workers'compensation policy inll)mrat ion. 'I f,.e,)w.:"who submit this affidavit indicating they arc doing all work and thin hire outside canimctors mint submit a new atlidavit indicating such. K?mnxwrs shut check ibis box must anached an additiotusl sheet showing the name of the sub-contnetora and their workers'comp.policy information. I out an employer that is providing workellrs'cootpeasadon insurancefor my employees. Below Is the policy and job site information. Insurance Company Name: `) .__._-- l➢� Policy 4 or Self-ills. Lic. d: C�— ' — ©�a Expiration Date: lob Site Address: 1 ` s City/State/Zip: ,,�.�eVA ©«�� 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 tine up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine ol'up to$230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I du lrereb cert/ under dr pubis mrd penalties of perjury that the information Bra vidrd buy e i true and correeL 4' m-t t r Data: A Z0 k� Phone t: Official use un y. Do not write in this area,to be completed by city at Iowa officiaL City nr'I'uwn: ___..... Pcrmit/I,lccnse#__________ Issuing Aulhurity (circle one): 1. Board of health 2. Building Department 3.Citylfuwn Clerk 4. Flectrical Inspector 5. Pltuubing Inspector 6.Other ._..__..— ---....___._.. Contact Person: Phone#: 1 4 CITY OF SU1 ENM N LkSSACHUSETTS BUIMING DEPART-MENT , 1 ` 120 WASHLNGTON STREET, Ya FLOOR " = TEL (978) 745-9595 KIMBERLEY DRISCOLL FAX(978) 740-9844 NL-ma THo.%tAs ST.NERRE DL4ECTOR OF PUBLIC PROPE11TY/31:11MI tG COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section i 11.5 Debris, and the provisions of MGL c 40, S 54; Building Permit t# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by t41GL c 1 11, S 150A. The debris will be transported by: y (name of hauler) The debris will be disposed of in -- - (name of facility) --__--(address of facility) signa ofparmitapplicant date Irh m,:ni J:: r 7- r e Massachusetts -Department of Public Safety , Board of Building Regulations and Standards Comtruction Supen isor Specialt}- License: CSSL.-105962, - DZMITRY KANA$E u w 402 PARADISE RD 3C A Swampscott M 6190 Expiration , Commissioner I.V30/2015 ' �I 1 P VfierA amIX+eal� •aaff''CkWZ'a,'(tKY�wjct&i R ++• ; • OBice afCousomer Affairs&.BusihessTtepl4ti" x,. OMEIMPROVEMENTCONTRACT0" e®istraGon: :'173034 1-1 ,. Type: , rt; xP60on.-8dW2014 �DBA ' f PRECISE HOME BUFI_DRS4Ll.C. - S' DZITRY KANANENK:X P � 402 PARADISE RD 3C - SWAMPSCOTT,MA 0190Y "—'—'— Uaderseeretary r v_ j