22-24 PARK ST - BUILDING INSPECTION (2) LKto3z
� The Commonwealth of Massachusetts
ny Board of Building Regulations and Standards CJMar2oll
Massachusetts State Building Code, 780 CMR S
Revise
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
"this Section For Official Use Only
Building Permit Number: Date Ap ie ::
Building Otticial(Print Name) Signature Dute
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numhers
---2-2--2f'Rv� 54 _ _ _
l.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 It) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(ivLG.L c.40,§54) 1.7 Flood Zone Information: 1.-Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal m
Check if yes❑ _�te
SECTION 2: PROPERTY OWNERSHIP' rn
2.1 Owner'of Record: C
I B (�, LLC ( ;sko.. Mn Gz(z.a , --E".
Name(Print) City,Stales ZIP >0
pLTrvrt�rvl s! Sut�� PODS 7$1 - -3057 rrc
No.and Street Telephone Enmil Addr• _ rn
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ E.xisting Building Owner-Occupied ❑ Repairs(s) ❑ Afteration(s) ❑ r ddity' ; ❑
Demolition ❑ 1 Accessory Bldg. Cl I Number of Units Other ❑ Specily:
Brief Description of Proposed Work`:_ weipv �F-.�k5 Ge4.'r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) y
I. Building $ 3soo 1. Building Permit Fee: $ Indicate how fee is determined:
�. Electrical $ ❑Standard Citylrown Application Fee
❑Total Project Cost(Item 6)x multiplier x_
3. Plumbing $ Z. Other Fees: $ _
4. Mechanical (I IVAC) $
5. Mechanical (Fire
Su))ression) $ 'Total All Fees:
Check No. Check Amount: _Cash Amount:
6. Total Project Cost $ �j`>0� ❑ Paid in Full ❑Outstanding Balance Due: --
G����D (o 2--1 I t
SECTION 5: CONSTRUCTION SERVICES 1
5.1 Construction Supervisor License(CSL)
t� CS-t.)32gv 61 zy K
License Number E.cpr Lion ate
Name of CSL Molder t
Y/ Ve r List CSL Type(See below)
No.and Street 'type Description
o191p U,> I Unrestricted(Buildings u to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
Cityll'own,State,ZIP
M Nfasonry
RC Roaring Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
IF7& --89-y—b66) $�oc9re�oeaktn� y �Hw�re I Insulation
Tele hone 9 Email address w7r D Demolition
5.2 Registered Home Improvement Contractor(HIC) 177h-!J
L Z05
�— IiIC Registration Numlxr Espiruio Date
HIC Comp m Name or I11C Registrant Name
No.and Street �r'IcSrPre.id^�'�'eavSGjc qy�p;�•e o
C.\r 11p a m 7 G g7;_ggl gob 3 1 Einail 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 Issuan9e of the building permit.
Signed Affidavit Attached? Yes .......... V No........... O
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
r 'to act ofilmy behalf, in all matters relative to work authorized by this building permit application.
r 'S
'Print Owncr'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:
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 NI.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basemenUattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces _ Number of bedrooms
Number of bathrooms Number of half/baths ___
Type of healing system_ Number of decks/porches—
Type of cooling system____— Enclosed Open
3. ,rolal Project Square Foolage"may be substituted for"Total Project Cost'
k
CITY OF SAiEM, NWSACHCSETTS
4
� BUILDING DEPART\lL-.\T
120 WASHLNGTON STREET, 3w FLOOR
T EL (978) 745-9595
Ake(978) 740-98-16
KI\1BE12LFY DRISCOL-L
INLAYOR T HonLks ST.PlEIRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
1Vorkers' Cmnpensalion Insurance Affidavit: Builders/Contractorv/Electricians/Plumbers
Applicant [nformatinn Please Print l eeibl
MitnC (Husines�,Org,tniratioro lmlividual): �ltc.L�� �r-.ew /
Address: yC 74. /
City/State/Zip: �`�`" /L/f� 01171 phoney: 478 85T —80�3
Are you an employer'!Check the appropriate box: 'rype of project(required):
1.❑ 1 am a employer with 4, ❑ I am a general contractor and
ployces(full and/or pan-time).' have hired the sub-contractors 6' ❑New construction
2. I ant n sole proprietor or partner- listed on the attached sheet, t r• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. g. ❑ Building addition
[No worker'' comp. insurance 5. ❑ We are a corporation mid its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.[] Plumbing repairs or additions
myself. (No workers'comp. C. 152, 91(4),and we have no 12.❑ Roof repairs
insurance required.( t employees. [No workers' j},❑Other
sump. insurance requircd,J
'.xnY applivmn that chucks but at most also rill caul the seniun below showing their workers'campensatiun policy iutiamatiun.
'I tomeownun who submit this atAdavit indicating they are doing all twrk and then hire outside contncton must submit a new afrrdavii indicating such.
$'•ntmcturs thul cheek this bus must inachcai can nddiliure,l shut showing Ilse n:une of the subeonincion and their wnrken'comp.Pulley infunnation.
f urn un mnployer shut is providing ivorkers'cuntpeitradart Atsuratice for my einpluyees. Udlmv is the policy and fob site
iu/ormmion.Insurance Companykre.Name: CO vewe I,"r-e d�TT
hSUra'`e-e
Policy if or Self-ins. Lic,0: B y DW RZ —$-._ Expiration Date: 0 S
Job Site Address: 27--ZH (G 9� . Cit !State/Zi �� ��
Y p:- �e t , n(),01`r-4,
Attach a copy of the workers' compensattou pulley declaration pug@(showing the policy number and expiration date).
Failure to secure coverage as required under Section 2J.1 of nIGL e. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to$25o.00 a day against the violator. Ile advised that a copy of lhis sratcmcnt may be furvardcd to the Office of
hrr,ligu(iunv of the DIA for insurance coverage verification.
l du hr reby cemfy a411Jer the pains all penultirs of prr%ury that the Lrfurruudan provide)ubuve is true and correct
S le; E — / Dare: --LA L?
Phone i
OJlicfal use only. Donor write in this area,tube completed by city car town o/Jirial
-try nr'ruirn: Permit/LIcense At
i.,uiag Authority (circle one): -- - — ---- - --
1. Board of llevfth 2. Building I)cll,Iment 3. Cityatoln Clerk I. Electrical luspeelor 5. I'lumbiug hupecwr
G. Other
11hone 1*
Cu noel Ise rsn n:
�lYf'T.
CITY OF S,UzNf, I.%L1SSAQgUSETTS
HLILDL`tG DEPARTMENT
120 WASHLNGTON STREET, 3w FLCOR
~`` ^ TtL (973) 745-9595
KIILI3ERLEY DUSCOLL FtX(973) 7-W434S
NLiY0;2 T,-{OSLU ST.PIEQIt$
DIRECTGR UP PLOLIC PROPERTY/8L:=LqG COSL\HSSIONER
Construction Debris Disposal Afttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 CLIJR section 111.5
Debris, mid dte provisions of MOIL e 40, S 54;
Building permit 4 this work shall be dispose is issued with the condition that the debris resulting firm
l 11, S I SOA. d of in a properly licensed waste disposal facility as defined by %fGL c
The debris will be transported by:
(n�ma ot'haulcr)
The debris will be disposed of in
--- - . S� ���, Puwl , 9
(name of taellily) -.
----_--I "le"of tilcitity)
1151W N(L'U()i CI"RIIt J)]L7(Kd11I
n.