1 PLEASANT ST - BUILDING INSPECTION (2) ` `�'D o�� - �4-Z-J
° 3 c� � � � a . _
_
ga The Commonwealth of Massachusetts
� Board of Building Regulations and Standards CITY OF
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
This Section For Official Use Only
Building Permi[Number: Date Applied:
�l� �,� ✓%� I° 23��
Building OfFcial(Print Name) " tature Date
, SECTION 1:SITE INFOR ATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
�. Q�as�r sra�c-r
I.la Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: � , 1.4 Property Dimensions:
Zoning Dis[rict Proposed llse I.,ot Area(sq ft) Frontage�(ft) � �
1.5 Building Setbacks(ft)
Fron[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❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
� Check if yes0 �
$ECTION2: PROPERTYOWNERSHIP�
�Jpntte� d �n �� 1 ' ICI✓ q� ' I q 0/ ! �1�
Name(Print) City,State,Z[P � �
a� w �'��,�w �2� �����3 ��°-C�c-��-���� , h�
No�.and S[reel � Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owneo-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition � ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Descrip[ion of Proposed WorkZ:
'�iY��c�-f-Q. V�.2,�V �1,�'G�t2.� �' '�lY(st3riL C7Vl l l�`� . tM✓
m SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofticial Use Only
. Labor and Materials
l.Building $ 2c� , b� 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $
���� _ ❑Standazd City/Town Application Fee
❑Total Project Cost�(Item 6)x multiplier x
3.Plumbing $ fp Qj(�U 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $2���,b0 �paid in Full ❑Outstanding Balance Due:
"IsL��L �a
S� �� �.� �
��
l�-'t.A�K�j5 c�i1L�lr� .
�
SECTION 5: CONSTRUCTION SERVICES -
5.1 Construction Supervisor License(CSL) �gn� �2 ���'�� .
!/f /
13�."GPQ.1 ��1/pc1�1,J(,IGG� LicenseNumber ExpirationDate
Name of CSL Holder � � I
5� ���r��✓��� List CSL Type(see below)
No.and Street Type Descrip[ion ,
i A �n�p,o����, ,� 'r,�_ b I�4h U Unrestricted(Buildin s u to 35,000 cu.ft. '
N�b"\�`—�d Wv'C R Resvicted I&2 Famil Dwellin
City/Town,State,ZIP M Mason
RC Roofin Coverin I
WS WindowandSidin I
�" ,,1� /'��� ,�-�.�/,,�/'�/�n,�A���� �.,�I SF Solid Fuel Buming Appliances
7� � lJ(���'Vv �71-V'1✓K-U�.GS-Jlyl�v-4.1�`� 1 Insula[ion
Tele hone Email address D Demolition
5.2 Regis[ered�Home�ImprovementCootractor(HIC) �� 1¢�c� �' ZZ �"
��'v� v�"T"w� MC Regis[retion Number Expiration Date
HT��m,pany������� egisvan�� ������� �
F�T i
iq., d ee[ �//�,,�O/gA/ yfj/��� Email address
Ll IiY/I� Y J �»
Ci /Town,State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION lNSURANCE 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 BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereb thor' e �riN ������lA��
. to act on my behalf,i a matters relative �o� k thorized by[hyis building pertnit application.
,, � ;�� ; �ol/�/i 3
'�-Prin. wner's Name{Ele. nic Signature) � . Dater .
SECTION 76:OWNER' OR UTHO ZED AGENT DECLARATION
By entering my name below,I hereby attest under[he pains and penal[ies of perjury that all of[he information
wntained in this applica[ion is true and accurate to the best of my knowl e and understanding.
^Yl�� �/�r�n1 IV�.�.�.l.�L-� �� I � � I � �J
Print Owner's or Authorized AgenPsTlame(Electronic Si ire) Date
NOTES:
1. An Owner who obtains a building pertnit[o do his/her own work,or an owner who hires an unregistered conhactor .
(not registered in the Home Improvemen[Contracror(HIC)Program),wi�l not have access to the arbitration . �
program or guaranty fund under M.QL.c. 142A.Other important information on the HIC Program can be found a[
www.mass.eov/oca Information on[he Conshuction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
To[al floor azea(sq.ft.) (including garage,finished basemenUattics,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 CosY' �
� The Commonwealth ofMassachusetts _ Print Form _�
Department of Industrial Accidents
Offzce oflnvestigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblv
Name (Busiuess/Organization/Individaal): GIOVANNUCCI BROTHERS,INC.
Address: 59 ATLANTIC AVENUE
City/State/Zip: MARBLEHEAD, MA 01945 Phone #: 781-639-4400
Are you an employer? Check the appropriate box: Type of project(required):
1. ✓❑ 1 am a employer with � 4. � I am a generai contractor and I 6. ❑New conshuction
employees(full and/or part-tune).* have hired the sub-contractors
2.� I am a sole proprietor or par[ner- listed on the attached sheet. 7. � Remodeling
ship and have no employees 'rhese sub-contractors have g, � Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 9. � Building addition
required.] 5. Q We are a corporation and its 10.❑ Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.� Roof repairs
insurance required.] t c. i 52, §1(4), and we have no
employees. [No workers' 13:❑ Other
comp. insurance requued.]
•Any applicant[ha[checks box HI mus[also£ll out the section below showing[heir workers'compensation policy infortna[ion.
t Homeowners who submit this affidavit indicating they are doing all work.and then hire outside contractors mus[submit a new a�davit indicating such. I
tContrac[ors Ihat check this box must altached au additional sheet showing the name oE[he subconVactors and sta[e whe[her or not[hose entities have
employees. If the sub-contractors have employees,[hey mus[provide[heir workers'comp.policy number. .
I am an employer that is providing workers'compensation insurance for my employees. Below is the po[icy and job site
information.
Insurance Company Name: LIBERTY MUTUAL INSURANCE
Policy#1 or Self-ins.Lic.#: WC2-31 S-361316-023 Expiration Date: 4/3/2014
Job Site Address: � ���n�K�� �+�I � �/nl�C/� i �� City/State/Zip: V ��7�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiraHon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penatties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalries 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.
I do hereby certi under the ains and penalties of erju that the in ormation provided above is irue and correct.
Si nature: - - —— . —__ - ---- — ----- Date _ __�_D_�_l l2���- ---'
I Phone#: 7 O � �P�j� �q"(�(�
Official use only. Do noi write in this nrea,to be completed by city or town o�ciaL
City or Town: Permit/License#
Issuing Authority(cirde one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
r
r
fit
t _
f r `•
1
I
u\
\% f
f
f ,
I
I �
1-0
I�o
l •
: 1 Z�adi.
rw
wj Jew op sh v�n9
y
upper �a� tne - -` • rn
I 1
I
I .
... ...._ i .
lid .. _ ..
_ ....... ...... _...... .......
i
j
7 :
i'
1
..... ._......
;
w
t
i
� C
.....
_ -....-. 12.I✓
,
:
r rnu��decl
ZS
y.
4