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9 MEADOW ST - BUILDING INSPECTION
The Commonwealth of Massachusetts a Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling Af This Section For Official Use Building Permit Number: Date Appl' ing Offic 1(Print 1 a ure Date SECTION 1:SITVNFoRmATfi6N IS Pr A d ess: 1. Assess Map&Parcel Numbers L la Is this an a epted Street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 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 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: �' Name(Print) �City,St I ate ZIP yrle No.and Street Telephone Email Address ECTION 3:DESCRIPTIO OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building R01 Owner-Occupied ❑ 1 Repairs(s) &rl Alterations) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other WISpecify Brie esc 'p ' n of Propo ed Wo kZ: _ v 40 SECTION 4: STIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building. $ ('� 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cosl3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due; SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor L' eynse(CSL) 2 ZG�..� License Number Expiration ate Name of CSL Ho der �� List CSL Type(see below) No.and Street• f�/ Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/To ate ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address I D Demolition 5.2 Jtegistered a Impyy��ovemen�tt Contractor(HIC) / ?� D. '75-� a t /{v OZD /Z x! !O HIC Registration Number Exp' anon D [e ;I (; y i;z or HIC Registr-r y r d it 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 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 lr, I,as Owner of the subject property,hereby authorize ��='—�'1 to act on my behalf,in all matters relative to work authorized by this building permit application. ZZ Print Owner's Name(Electronic Signature) IDad 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 ap l-�ip}anon is tine and ac rate to the best of my knowledge and understanding. _ `C==r7Gt/G�i(J U Print Owner's or Authorized Agent's Name(Electronic Signature) Datdf 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,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' . ' 5v 0 CITY OF &UEN1, iMASSACHLSETTS BUMDING DEPARTSEEHT a 120 W ASHINGTON STREET,leFLOOR'IL (978)745-9595 FAX(978) 740.9846 KINIBERIEY DRISCOII T MAYOR �iOb1AS ST.PiFltRli DIRECTOR OF PLBLIC PROPERTY/BUI DLNG COMMISSIONFR Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prin bt / I .�' Natne(Busitxss:0 nizatioNlndi idual)' /� b(!V Address: Dr _ hone City/State/Zip: l.G�� s© P #Z Are y an employer?Check!hp appropriate box: Type of project(required): 1. ' 1 am a employer with -4— 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-tithe).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity, workers'comp,insurance. 9, ❑Building addition [No workers'comp.insurance S. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ t am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12. wf repairs insurance required.]t employees. [No workers' comp. insurance required.] I3.❑Other Any applicud that dnxka box 91 most also till out the section below showing their worker`eompensadon policy information. '1 tomeown�rs who submit this affidavit indicating they an doing all weak and then him outride contractors must submit a inter andsvil indicating such. =Conimetan that cheek this hex nmt,,ttached nn additional sheer showing the name of tha aub.contrctors and their workers'comp,policy infonstiodon. lam an etaployer that is provid r rs'compensation tnsarance jot my employees. Below is the policy and Jab site information �? Insurance Company Name. d Policy#or Self-ins.Lic.#: Expiration Jab Sire Address: City/State/Lip: Ci Attach a copy or the workers'pilapiesuation policy declaration page(showing the policy number and eipl4dort state). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of fine up to S1,500.00 and/or one-year imprisonment,as wail its civil penalties in the form of a STOP WORK ORDER and a fine Of up to S250.00 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. Ida hereby cerrijy an e t e pain Is n 11es ojpedury that the information provided above i trite and c reeL ho z 3 Official use only. Do not write in this urea,to be completed by city or tdwa afeiaL City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: aCITY OF S.u.&Ni, NWSACHUSEM BUILDINGDEPARTMENT 130 WASHNGTON STREET, 3" FLOOR TEL- (978) 745-9595 FAX(978) 740-9846 (O�{gFRr FY DRISCOLL MAYOR T Hoarns ST.PtERR& DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG CMMSSIONER 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 t ^�;7' (name of-facility) t 4— (address of facility) signature of per tt applicant date dcbriviT.du: 1;•r mua iunrul/�r/ r./(uJ;errw.�rlG !_ Office of Consumer Affairs 6 Business Regulation License or registration valid for individul use only CFI �OME IMPROVEMENT CONTRACTOR --' 2e istration: 166178 Type: before the expiration date. If found return to: I e 419_ g Office of Consumer Affairs and Business Regulation ' V, ' Expiration: 5/5/2014 Individual - 10 Park Plaza-Suite 5170 STEVEENN HIOU Boston,MA 02116 - • STEVEN HIOU i 2 NEPTUNE RD. g� _ E. BOSTON,MA 02128 Undersecretary Not valid without signature 1�f Massachusetts -Department of Public.Safety i Board of Building Regulations and Standards 111� Construction Supervisor f License: CS-103080 I STEVEN C HIOU = _ 2 NEPTUNE ROAD AP.T 140 c ! EAST BOSTON MA 02128` !" ' Expiration ! Commissioner 0112 712 01 5 • Jlcv<'/rUr// .,,,� License or registration valid for individul use only & Busn�cs /�r Yr r.ur�irr:rircra�/� r s Reguulation r j4 office of Consumer Affairs .t y before the expiration date. If found return to: ` Office of Consumer Affairs and Business Regulation f �t IIOME IMPROVEMENT CONTRACTOR Type: ;I 10 Park Plaza-Suite 5170 I egistrationc 162020 y ` DBA �• 1_xpiration: 12/26/2014 r Boston,MA 02116 r KING'C-6 ONSTRUCTION r c r / t HIJARIO VASQUEZ I /� < _rt 26 AGAWAM ST.APT#1 - ��a�'-' 'E� t } Not valid wit __Yhout signs Undersecretary - '! - LOWER,MA 01852 L/ VVL raA OOi VWZ CERTIFICATE OF LIABILITY INSURANCE DATEIMNUDD rn TtIL.MITIMEATE IS 11103 AS A NATTER OF INFORMAMON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S).AUTHORIZED REPRESENTATIVE OR PRODUCER.AND THE CERTIFICag IMPORTANT:If the certlNeate holder is an ADDITIONAL INSURED,the po0eylies)must be endorsed_ It SUBROGATION IS WANED,subject to he terry and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to he cartiteats holder in lieu of such endorsem s. PRODUCER - CONTACT HAW- Cloutier Ins. Agenc_:• - PHONE FAX 1996 Lakeview Ave. (A/C,No,6D): LAC.No). Dracut, Ma. 01826 E-MAIL 28YYX ADDRESS: INSURERIS)AFFORDING COVERAGE HAIG a INs_'RID .. - INSURER A: 7a—A*.Dt._-_;, i INSURER B: Hilario Vasquez INSURER C: ; Steven Hiou P.O-BOX 9634 _ INSURERE Lovell, ma_01852 INSUR6N F: � OOvlRAraEs CERTFF(CATENUM66i: RLMMON NUANUR: TRW IS To . RAISED ABOVE OR ®T "TNIUM,-HT NItaIRIEWIT T6W OR CDNMTWN OF ANY CONTRACT OR OTNER COCUMBff WITH RESPWT TO WMCH T C1 MM^Ts=v 6e rsau®so auv FERTABL TUDIVIRANNA"baftiOAT iYaiOrt«OFSCfm®KERIM ISSUSJECT TO ALL THE TERSTS,EWLUSIDMAKO CCKMMNSOFWM PCIMES. 1-1119 MOYMAIAY HAVC a®I REWC O eY Pao GJI2M ... 00 sua POGLCY EVF GATE cv sllo"Ta LTR TIPEOTQ®IRAICE L R POLLY NUMBER mooDDnYYY) (A69ppWy'r" YMTS el OCCJJRtl£H^E CtlAL LIAOILrtV ^_�S - ^H a UkER.^,=AL G$±ER.1L L:A61�v Ep— .EIdISEs{E3mac.l EXP iAnj vo Faranl �NL AUGRE3A-E L",'7 APPLES PER INN.6 ADV IN:V(iY .5 -ErVEfiAL LATE :3 PCL-0+' �PRO_EO' OLo.: -UU 'S-COVP;0PAaa 9 AUTOMOBILE LIABILITY V6-NED 43NGLE iNr au:� •�;?Lea a�aa1A) - ALL OWNED AUTOS My 3U?.RT ;5 SCHEDULE ALT'64 n17rtiNJlraEC AV-*3 Par amiaFRl .. Par�a�iasM) L''JORE1LA L:AE OCCUR ACH OW-HIRENrc .3 _ .._..... . IXCESSLAB I IOIXYS-VAI:S D�L'1Y718LE _ _ WORKtOrG CONPIENIMI1ON AND &UPLOYOM LIABIJW YM U84M 8NSOA-13 04/43H3 CIM3114 uwm x�v ssa�—r•.�_R'�a. ^,.-v_ NIA E L EACH A=Ce,,1T .i o iCC.CCC ty^^d^I�'Y^` 1 EL CSEASE-EA Etr'L6'.'EE S TOG GGG El D'SFA4E-POLIC L'+Yi- 'i 5^,.5 BOG DE CCPSMON OF OPOtATKMSILOCATIONSMHCLES/MWMCTKmMPEMAL 17EM5 CERTIFICATE HOLDER - - CANCELLATION ! SHOULD ANY OF THEASOVE DESCfiIB®POUCt6 BE CANCEL i BEFORE THE E)PIRAT10N DATE THEREOF.NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, i AUTHORIZED REPRESENTS iw-[JI. t..-�f•.....� ( O/ a D name and o are re stared manta o CON ISM2010 ACORD CORPORATION. All rights reserved. CONTRACTORS INVOICE [ � WORK PERFORMED AT. r s- sue, TO: E /� v DATE YOUR WORK ORDER N0. OUR BID NO r `( � � • it v e U ao 7 All Material is guaranteed to be as specified, and the above w k was per rmed in accordance with the dra a d c' ications provided bove w as completed in a b tial wo nlike manner for the agreed sum U This is a ❑ Partial ull invoice due and payable Mont Da /� Year in accordance with our Bement .❑ Proposal No. Dated M Day Year TC8MADE IN USA CONTRACTORS INVOICE ntlmru MADE N L