101 MASON ST - BUILDING INSPECTION (2) I'hc Commonwealth of Massachusctis
y; l� Board of Building Regulations and Standards CITY OF
(r ') Massachusetts State Building Code, 73D C'NIR ti,\LI:\I
�O L,•• R.'rireJlLu'_`llll
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One-or rnv-Furrri/r Urrellhuq
This Section Fo t'ricial Usc Onl
Building Permit Number: Dale Applied:
wilding Otl-mal(Print N;unc) Signatu Owe
SECTION I:SITE INFORMATIO
I. roperly Address: e� 1.2 9ssessors b S Parcel Numbers
1.Is Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions.-
Zoning District Imposed thie Lot Area(sy II) Fmnluge(II)
1.5 Building Setbacks(R)
Front Yard Side Yards Rcar Yard
R
equired Provided Reyuircd Provided Reyuirvd Provided
er Supply:(M.G.L e.40.§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Private 0 zDtle: — Outside Flood Luna? Municipal 0 On site disposal s)stem O Check it' �esO
SECTION 2: PROPERT .OWNERSHIP'
er'of R ord
hn')' ('ity.5 • e,l.IP
- �9019
treet hone Emuil Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
struction O Existing Building 0 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition 0
n 0 Accessory Bldg.❑ ritber of Units Other 0 specify:criptionofProposed Work':
SECTION J: ESTIJIATED CONSTRUCTION COSTS
Item Estimated Costs:
'Labor and .\hsterials) Official Use Only
I. Building S I. Building Permit Fee•. S Indicate how7isermined:2. Electrical S 0 Standard CityrTossn Application Fee
0 Total Project Cost'(fleet 6)x multiplier __
1. Plumbing S �, Other Fees: S_ -
J, mQ01anical III\' W)
5. \lcchanical (fire S —_--.-- — — -- .._ - ._-. ._ . .
\u i vosion l total .\II Fces: S
CheANo. Chcck:\nwunt: l',ish \ni..um:
o Tidal I'ntjccl Cuss: S P;:id in Full -- ❑Outstanding Ilalance Duc:
/ I
SE( FION S: CONS TRU<"rION SERVICES
5,1 Cun.1 tion Sullen isur License(('Si,) Z
5- 241/41
I icoiw Number I \piranou Dale
N.1111e 11 M. I larder
I ist CSI. I)Pe hoc heluwl-_---- _--.—
!� I)P: Description
No. anJ,lrcct /)
U I hucsuioed Illuildin ms ti to ls.11lln cu. Il.l
R Rnlri led L@] P.unil Il++cllin
Cil,i di„n,.tit:ne,LIP O --_— -_ •\) Nhul�n
tJ t41yS RC' RtMld l.'ocerin
{ W'S W'indoe ,ud Sidon
SF Solid Fuel[)timing Appliances
huulatiun
'I'ele hone J h:mail aJJrese D Demolition
5.2 Registered home improvement Cunfntctor(FIIC)
~ IIIC'Itegistration Number lispirutiun Uute
I IIC Coulpan) Name or I IIC Itegistrult Nine
No. and Street Email address
Ci [Town,State,ZIP Tole hung
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L e. I52.f 23C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affldavit will result in the denial of the Issuance of the building permit.
Signed AfMdavitAttached? Yes..........Cl No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize �!j2L\� 'd^
to act on my behalf,in all matters relative to work authorized by this building permit plication.
mooI,,
) V. 1�udrs �- 2 - / a
Print Umicr's Nurse([ileclrunic�Signlaure) Data
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.
I'rilll D„ner's ur:\ulluldreJ.\g¢n19 None(Gkelrullie SignaUlre) note
NO'rES:
FTnI. An Owner ss obtains a building permit to do his•her own work,ur an owner who hires an unregistered cuntractur
[not registeredhu in the Hume Improvement Contractor(HIC) Program).will no have access to the arbitration
program or guaranty fund under NI.G.L.c. IJ_'A.Other important information on the HIC Program can be round at
WM 111.11, �"', .,,.I Information on the Construction Supervisor License can be found at
I When substantial work is planned,provide the information below:
Total tloor area I sq. R.1 - __.,_1 including garage, linished basement attics.Jerks or porelu
Gross It%ing area Isy. it.l habitable room count
\umber of lireplaces ... _. ._ .. —_ \unlher of bedrooms .. .. .. . .
\umberof halhromms . . - . . Number of halfhaths
11 lie of heating sy sleml \luuher ol'Jecks• porches
1
I 1 l,e of eoolillg s,ilelll I`.IleloxJ ( I,dll
I
1. "h,i,d Project SyUare Footage"nl;l) he suhstowed li,r"folal Project lost"
Q-1-Y OF 5.1LE.1,[, NWSACHUSE"LTS
BUILDING DEPAIMLE-\T
it 120 C//.1SHLN(;TON STREET, )ta FLOOR
TEL(978) 745-9595
F.kv(979) 740-9844
Kl.\(13 RI Fy DIUSCOL
�L�YO.Z TNo�t�s ST.PtE.aRH
DIRECTOR OF PUBLIC PROPERTY/BURDINC,COI\6tissIONER
Workers' Compensation Insurance Affidavit: Builders/Contractucv/Electrici"rne/Plumbers
%oolleant Inform"rtinn ] J Please Print Legibly
Note tiplll +4Of an4altW e I NIIV III Mill: �� W r�✓v'� y/
Address: v
CilpStatc/Zip: e.Ll1-0� b1rcL IIhunaN: A63 5 !O
Arc you an employer?Cheek the appropriate bolt 'type of project(required):
1.❑ 1 am a employer with j. 0 I am a general contractor and 1 6. 0 Now construction
et Ioyces(full and/or part-time).* have hired the subcontractors
2. 1 am a sale proprietor or partner. listed on the attached theca i 7. ❑Remodeling
,hip and have nu employees These sub-contractors have 1. ❑ Demolition
working fir me in any capacity. workers'camp, insurance. 0. 0 Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its
nyuircd.) officers have exercised their l0.❑ Electrical repairs or additions
).0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myseiL(No workers'comp. c. 152,41(4),and we have no 12.0 Roof repairs
insurance required.)t employees.(No workers' U.❑Other
comp. insurancercquired.)
\ny applk:aw dW ahcaks but/1 mtwt also Nl out the xttiw bufow vhowing their"k4o'eomp.nudun pugcy innnmYtlon,
'I1,"vowm"who.uhmil this anlMvit Indicaing they an doing all work and than hire wuidir kontrtcicn mtut mhmll a now alyfdavil indicting luck
t'amnwton that cM<k this box tout.machad an.Iddilerud.hest shuwing IM owns or the.ubsuiamtun and their woken'wmp.policy Infomtadoe.
fore on eurpluyo chat G pruvfJLrX rvorkers'cumpreaarlun buarunn jot my nnpfaydrx Below/1 the polty undfob alb , • r
injurnmrinn,
In,umnce Company Name: _........_
Policy 4 or Self-ins. Liu. 4: Expiration Date:
Jub Site Address: City/Statc/Zipt
tlaeb a copy of the worker'compenratloo polity declaration page(showing the policy number and expiration dato)
h'ailuro to weuro coverage as required under Section 25A of bIGL c. 152 an lead to the imposition of criminal penalties of a
rice up to S1,500.00 and/ur one-year impri.mmncnt,a1 well as civil penalties in the farm of a STOP WORK ORDER and a tine
ar up ua M0.0a a day against the violator. Ile advkvd that a copy of this statement may bo furwardcd to ilia Of tiro of
Invr,ligatiuns Ali the DL\ tsar insurance covenyc veriticaliun.
1,10 hereby rrrrijy unJe{•N pains mrJ penu/tlrr ujper%ury tbur the ipjurnrmlmv provided ubuve iv true ouJ correct.
c
ii.... f I .1/1� Dilra:
Official nee only. Ora nor writs he drr.v area,ro hr cuerplNeJ by city ar town,Jilt iut
City or I"i'vu;.___. _ __. Permitii.leenve 4
I,.uia;.\udwrily (circlo one): —_. . ...__ ....
1. Board of health !. Iluildlm; Dep.Irtmcnl 1. Cily,fawn Clerk 1. b.leetrieal Inglcclor i. Plumhln4 Iplpeetor
!. Other --- -----._.
L�nllad 14rwn: Phnoe h
Cm of S.VzNr, Alss.tcHuSE-ITS
uLtcn�tc DEP.taTatevT
I 'O Iff-Um VGTON 5TXW' 114 Ft001t
rEL (973) 741.9599
KnOFAI Y OUXOLL F.Vt(973) 740- 44
1UYOlt mcimuST.Ff A"
0 flum itOPPLSucPROPFATY/at:RpclGCO.Aalfssla%EI
Construction Debris Disposal At'fidavit
(required for all demolition and renovation work)
In aceardance with the sixth edition orthe State Building Cadet 730 Cb1R section 1 I I.I
Debris, and the provisions of MCL o 40. S 54;
Building Permit a is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed wusts disposal facility as defined by MGL c
111, S I BOA.
The debris will be transported by:
'(muss of haulu)
The debris will be disposed of in
(name or fudily)
( Jdrera or'r�,ih�y)
n.mreor;ermif h.+nt — C./
U
? Massachusetts - Department of Public Safety
` Board of Building Regulations and Standards
Construction Supenisor
License: CS-011397 ,4, s.
DAV1D B.BYORS_`11
27 Haley Rd 2 ;
• Marblehead MA:01945 _
a
Commissioner Expiration
05/06/2014
.:. , 6vt
L 64cV
(oI1 din qj
` f +�1
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