183 NORTH ST - BUILDING INSPECTION ,
(� y� The Commonwealth of S4assachusetts
Board of Building Regulations and Standards CITY OF
qo
Massachusetts State Building Code, 780 CNIR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Oflj ' l Usi Only.
Building Permit Number: D e Ap led>_ '
Building Official(Print Name) igna:. Date
SECTION I:SITE INFO NIATION
1.1 6raperty A dress: 1.2 Assessors Map& Parcel Numbers
13 +yofr4
1.la Is this an accepted 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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2:; PROPERTY'O�VNERSFIIP{'
2.1 Qwnert of Record:
1gr1l MCA 3 1 q 70
Name(Print) City,State,ZIP
No. and Street Telephone Email Address
SECTIOtY 3: DESCRIPTION OF PROPOSED WOR]e'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': t (l
SECTION 4: ESTENL4TED CONSTRUCTION COSTS
Estimated Costs:
Item Off2eial Use Only
Cabot and �.latcrials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
7 Standard,.City/Town Application Fee
3. Glactric;d y ❑Total Project Cost(Item 6)x multiplier x
3. plumbing i 2. Other Fees: S
1. Meehanic.d (IIV.\C) i List:
i. Mech.uiical (fire $
5n > >ressiun) Total All Fees:.S
00 Check i to. __Cltcck Amount: ("Ish Amount.___..--
� 1'ntsl Project ('u.iL 170. f ❑ 11,:id in Fnll 0 t)utst:mdim, 11;il111ea 011:
SECTION 5: Co)NS rRUCrION SERVICES
5.1 Contrucliort Supervisor License(CSL) J-016
68--
Can Ll License Number E4pi otiun Dato
N;une ot'CSL Holder 1 List CSL type(see below) U
t�c7 2t�T �G S t ryPC Description
No. and Street IJ Unrestricted Buildin s u to Ji,000 cu. t.
tM 1 02� R Restricted 18e2 Family Dwelling
City/rown, State, LIP NI �lasonr
RC Rooting Coverin
\VS Window and Siding
SF Solid Fuel Burning Appliances
CyynT7. Sl �l�/rlf}1R�o� I Insulation
D Demolition
rele honC Emad uddrcss
5.2 Registered Hone Improvement Contractor(IIIC)
H[C Registration
Number /Expi atiun Uate
I IIC Co pany Name urn.(IC Registrar N;una MCl�'Ifj¢� \U t 1-16I- --M
iotn5 b
1�. and Street Emall a ress
�., rc"�� 5� �1J111PfJ c/���1-�302
try/ wn,State, ZIP Telephone
SECTION 6: WORKERS' COMPENSA'r[ON 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 DE CONIPLETED WHEN
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.
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
contain in this applic, 'on is true and accurate to the best of my knowledge and understanding.
(riot con r or Authorized:\gent's Na e(Electronic Signature) ate
NOTES:
I. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(nut registered in the Hume lmproveinent Contractor(HIC) Program), will Lint have access to the arbitration
program or guaranty Rind under M.G.L. c. 142A. Other important information on the II[C Program can be found at
www nut:.�uvioca Information on the Construction Supervisor License can be round at www.nta.,.•'u� o'JL
2 When submatuinI work is planned,provide the information below:
1`otal fluor area(sq. I __ —(including garage, tinislwd basamenUattics, decks or porch)
Gross living ;trot(sq. 11.1 _ Habitable room count
Nwnbcrorlircpl,iccs,_ _ Numberorbcdroums
-----------
Vnotbarul hat hmuitts _-_--- Nut tiller orh:d['batlu __..----_.__-- --
1'vpe trhe.uingiy.tain Ntimherurdacks/porches ------
- - --------
I •,l?C,tieonlin� <vaem _ _ , P.nclo;cd ()pen ..- .
Syun� Poart,tgr" ut.ty he ,iib;ttnudd t,,l I'„t-il IYwyert l', t
,.
Cx The Commonivealth of Massachusetts
Department of lndustrialAccidents
—( Office of Investigations
j 600 Washington Street
Boston,MA 02I1I
l www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information M Please Print Legibly
Namo(Business/Organization/Individual): On Z L '
Address: ",
City/State/Zip: Y�)Gn\,)er:!� Cy)C3 Phone#: 978
Are you an employer?Check the appropriate, Type of project(required):
LEI I am a employer with 4. am a general contractor and I
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. [Z'Remodeling
ship and have no employees These sub-kontractors have g. Q Demolition
workingfor me in an capacity. employees and have workers'
Y P t3'• 9. ❑Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repass or additions .
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t C. 152, §1(4),and we have no
emE]oyees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. -
t Homeowners who submit this affidavit indicating they aro doing all work and then hire outside contractors most submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. \_ 1
Insurance Company Name: L c o ) (� i�y `(Y�`3-�uc.,A.
Policy#or Self ins.Lie.#:VJ -CS 'J.t 5-. 4 13 117 5 - -3a- Expiration Date: o ` ate'
Sob Site Address: C,y/STate/Zip: [)j Ct/j"
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
fore up to$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. 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 certifyU)i)�der the pains and en aides ofperjury that the information provided above is true and correct.
Signature: /JAB 17��Y/ Date: <1/,2313
Phone#• 97A-W5/-69U;Z
Official use only. Do not write in this area,to be completed by city or town official
City or Town:. Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Towu Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Amass®OT CERTIFICATE OF REGISTRATION RMV Division .
y"JD=''�"v`o,M;;,:J1„��I�: M.G.L.chapter 90 section 246 makes it a crime;to alter this Certificate� CiD NG,BAH
a-04 DATE MONTH 09 02210073030117
REGISTRATION TYPE 12
PLATE iVPE BEGIsi PhTION A'OMBEn 04/09/12 r '
MCN WZ5228 MOTORCYCLE .F V:�HICLE TOTAL REGISTERED .
cCIOR Not valid vrithout official 'CARRYING WEIGHT FORA
IAODEL BODY SYL6TYPE PASSENE. ORTM ILER.VEHICLE
MFRS Mona TEAR MANE MOTCY BLACK signature of Registrar FOP HIDE, oPTRAILER.
2001 HD RL 12 0 0 PEGIsrPAfl NUMB R
TITLE NUMBER NNERE GER
INEJPANCEfAMPANV PASSENGERS
V"cNILLE IOENIIFIG4�IDN rNNBEP THAT CAN 9E
IHDICGPI41KI47719 PLYMOUT14 ROCK ASSU BE40263 n ,l n� KATED.
RES10EWIAL ATUPt-11F DIFFERENT)
FEES
NAMFS)OF OWNERS)AND MMUNG ADDRESS REGISTRATION 100 .00
MiANZI, STEPHEN P TITLE 0 .00
36 PURCHASE ST SPECIAL PLATES 0 . 00
DANVERS, MA 01923-3641 SALES TM 0 .00
TOTAL 100.CD
MASSACHUSETTS DEPARTMENT OF TRANSPORTATION
REGISTRY OF MOTOR VEHICLES DIVISION
The records of the RMV database constitute the official status of the vehicle registration.
CHANGE OF ADDRESS
SPECIAL MESSAG"c
IF THIS VEHICLE IS NEWLY ACQUIRED, IT STREET ADDRESS
MUST BE INSPECTED WITHIN SEVEN (7) DAYS
OF REGISTRATION.
CITY,STATE.ZIP CODE
Important Information for Vehicle Owners
.Return the registration plates to the RMV immediately if:
. Every person operating a motor vehicle shall have the Certifi- -The vehicle has been sold or junked and the registration is not
cake of Registration for the motor vehicle and for the trailer,if
any, and his/her license to operate,upon his/her person or in going[o'be transferred to another vehicle. Keep a co of the Rill
the vehicle, in some easily accessible place. of Sale, Title, and completed Reassignment of Title or your
By law,you must report any change of address to the RMV within records to document the transfer.
13 days in writing. Address changes can be made on the RNiV -You move to another state and you register the vehicle in that state.
website: www.mass.gov/rmv or by mail to: RMV,P.O. Box 55889, The insurance policy is not renewed or is cancelled and there is
Bostonchange to t MA ou
he RMV,pleas05-5889.see wrince te corou recteve d address ilorted the l e39 no plan to obtain a new policy.
provided above.
Transferring Your Plates: Massachusetts law (M.G.L. Chapter 90, Section D allows YOU to transfer valid registration pla of tes from thisst
vehicle be meta 1 Vou are a in
t teasstt 18 years of new or eage and Vou own thecitor vehicle or amotoriler nvlehicclle or trailer identified on this Reg stratioin insurance and a new n Cerf fcohe, 2lYoul[transfer
_
ownership of[his vehicle to another person or permanently lose possession of It(such as through repossession, etc.);3.The newly
acquired vehicle is of the same vehicle type(passenger vehicle to passenger vehicle,trailer to trailer,etc.);the same registration type
(passenger to passenger,commercial to commercial); and has the same number of wheels;and,4.The seller and buyer properly
complete the Assignment of the Certificate of Title(for the newly acquired"used"vehicle)or Certificate Of Origin(if a"new"vehicle). if all
with the
ates up
tof the above are met,you may operate he date of transfer(qr loss of possession). The day of newly utra acquired
or loss i5 day p1 transferred
Dunn9 thlose 7 tlaVs Vou must carN the Rill of Sale of the 7th calendar daor tlthewing
dealers Pmrhaye Contract)for the newly acquired vehicle and this Registration Certificate when operating the vehicle. See F.4 Qs About the
Seven-Day Registration Transfer Law On the RMV's website at www.mass.gov/rmv. _
No Insurance Card Required:Massachusetts's law does not require an Insurance card. The
law,M.G.L.Chapter 90, Section 34A and
Chapter 175, Section 113A requires the venicie's owner to maintain a compulsory motor vehicle liability insurance policy or pond for bodily injury
coverage and property damage insurance. If an insurer is identified on the face of this Registration Certificate, it is required by law to
electronically notify the RMV(Registry of Motor Vehicles)if coverage lapses.The vehicle owner Is then notified by the RMV to obtain new
insurance within 10 days or the registration will be revoked.Bonds are filed with the State Treasurer S office.
BE FIRST IN LINE BY GOING ONLINE AT WWW.MASS.GOV/RMV
Schedule a Road Test Request a Duplicate Title NEED TO VISIT AN RMV OFFICE?
Renew Your Driver's License Request a Duplicate Registration SAVE TIME
Renew Your Registration Change Your Address Complete Your
Pay Citations/Court Hearing Fee Cancel My Plate/Registration Application Online!
Replace Your Driver's License Order a Special Plate
VISIT OUR WEBSiTE FOR A FULL LIST OF AVAILABLE TRANSACTIONS ;PI9BB,i Vaal
CITY OF S.0 ENf, NLUSACHUSETTS
BI;ILDL1'G DEP.hRTIE.NT
120 WASHLYGTON STREE'C P FLoom
-ML (973) 745-9595
ical E.RL£Y DRISCOIl FAX()78) 7 f0 934b
NUYOR DIOu"ST.P MUM
DI.TECTOR OF PUBLIC PROF ERTY/8CIIDLYG COdMISSIO.NER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 C1VTR section l 11.5
Debris, and the provisions of tbiGL 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 bIGL c
111, S 150A.
The debris will be transported by;
f�nC Z
(name ufhautcr)
The debris will be disposed of in :
(name of racuity)
(address or facility)
sign' rc of permit applicant
J.uc --