Loading...
14A RAYMOND RD - BUILDING INSPECTION (2) Y +�/ ^ The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF � Massachusetts State Building Code, 780 CNIR SALEM dMar Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Divelling This SectionFbr Offici se Only _. Building Permit Number. Date pplied U� Building Official(Print Name) `. '.'Signatur0 i.` - Date - SECTION I:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map & Parcel Numbers 1.l a Is this an accepted street? yes ✓no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: t� l 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 ❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2:, PROPERTY IOWNERSHDN' 2.1 Owner'of Record: r^ +L Alo", 1&1)e-z k Ci---� U -IName(Print) City,State,ZIP ira a 4A CAA 5-&-6S-7-L1615 Gl , ;�a nPz No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF.PROPOSED WORK (check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work: Df n r r, `l—. QtAlA Q C aS 0 c -1 SECTION 4: ESTIMATED CONSTRUCTION COSTS , Item Estimated Costs: I Official Use Only.., Labor and Nlaterials I. Building $ 15 1 Building Permit Fee $ ' Indicate how fee is determined: Electrical $ ❑ Standard Cityfrown Application Fee 2. �'� ❑Total Project Cost' (ltem 6)x multiplier x 3. Plumbing S 2. Other F'zes; 4. Nlechanical (IfVAC) S List: 5. Mechanical (Fira Su� ression) Total rVIl Fers: .S Check No. Check Amount: Cash Amount. 6. 'rotal Project Cost: S \5 ,C� I ❑ Paid in Full ❑ Outstanding Balance Due: ��-day • r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL.) S--}- %. �AeA% c � _ License Number Expiration Date Name of CSL Bolder t ((�� List CSL Type(see below) -a© O S ��.e�r� tCC� • — Type Description No. and Street ` U Unrestricted Buildings up to 35,000 cu. tt.) C!>I Ci0-1 R I Restricted 1&2 Family Dweihn City/Town, State, LIP bt blasonr RC Roofing Coverin WS Window and Siding SF Solid FIICI Minting Appliances {=7a4^�S1Ci`l L'Nlad:'ca4 ((,i,J) �(e.r:5�+. ,tr1E. I Insulation "I'de hone Emai address D Demolition 5.2 Registered Home Improvement Contractor(HIC) v-1Ia--II y�y,R,'t q, " + C'A- H[C Registration Number E. pirati n Date HIC_ Coinpan pac eorIlf( R�gistrant�a % ,, j + Z �] tK "61L'.�� �l Lft Sin VIL N and Street Email address ^1iSt City/Town, Stafe, 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 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 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 SF,CTION 7b: OWNER' 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. e Oner's' or Au[tooted:\gent's . ante(Electronic Signature) ate / (Yuu w 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 isLG.L. c. I42A. Other important information on the HIC Program can be found at www.m:us. ovioca Information on the Construction Supervisor License can be found at wtvw•.rnass.eo�:411t�; 2. When substantial work is planned,provide the information below: Total floor area(sq. R.) _(including garage, finished basement/attics, decks or porch) Gross living atea (sq. ft.) Habitable room count Number of fheplaces.-- _ Number of bedrooms -- Number of bathrooms _ Number of half/baths _ Type of heating system _.—_-- __ Number of decks/ porches--- I'ype of Cool in" system ------ — Enclosed_- ---Open -- ). `total PrOjeCt Squ:ire Footage" may besubstituted tOr"Total PrujectCmt" CITY OF SMEM, ANSSACHL SETTS r ' v BUILDING DEPAIMWDiT 120 WASHLINIGTON STREET, 3te FLOOR TEL (978) 745-9595 FAX(973) 740-9846 lU\fBEM_EY DRISCOLL �1AYOR THoatAS ST.P>FxRa DIRECTOR OF PUBLIC PROPERTY/BUILDL`IG CO-salISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly Nat'ne(Busiiws.&Organirariamindividual): Address: o rr' tn.,4rv4 DA. City/State/Zip: SI` eMSA Qbj OU CW46—Phone lE: Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with 4. 0 I am a general contractor and I 6. ❑New construction ployees(Nit and/or part-timo).• have hired the subcontractors 2. 1 atn a sole proprietor or partner listed on the attached sheet t 7. ❑Remodeling ship and have no employees These subcontractors have 8. (] Demolition working for me in any capacity. workers'camp.insurance. 9. ❑ Building addition (No workers'comp.insurance S. ❑ We are a corporation and its required,) officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workers'camp. c. 152,01(4),and we have no 12.(] Roof pair 1 insurance required.)t employees.LN0 workers', 13. ther (c),"ad comp.insurance requircd.l •Any appikato that altwita box r I mutt also fill uta the section below showing their wurkeo'mmpemodon POLY inrurmatlon. '1 Lvncuwncre who submit this affidavit indicating they am doing all work and thin him wuidecontractom most submit a new affidavit indicating rash. �Gmin tors that chick ibis box most attachod an additlunul ahaat showing the name of the subaantncors and their workers'romp.policy Infomrdoe. I um an employer that Is providlog iverkers'eompensadon Laurance for my employeex Below Is the policy and fob site information. w � ii Insurance Company Name: 0/'�T�f i V 1JJ C; 1 Policy d or Scif-ins. Lic.n S Z — -6$O — ' Lp O i 4 T� '�" a iration Date: i7 1 1 144 job Site Atldrum: 4L( A 2A:A ft.v1.r�, jpL . City/State/Zip: 12,E AAA C56 70 Altacls a copy of the workers'comp nsation policy declaration page(showing the policy number and expiration data). Failum to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 andtor one-year imprisonmen4 as well as civil penalties in the form of o STOP WORK ORDER and it line of up to S250.00 a day against the violator. Ile advised that a copy of this stalement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification /do hereby certify sander the pules mud peuuhlas of darlsoy t/ml rht iafarnutlmr provided above is true and correct iicnantre:�—�� �Ill.i^ Data: a 114 1 roe,i: "7,1s OJJic fal use unly. Do not write in rhb area,to be completed by city or lawn oIJlrlat i City or'rown: __,.,, _ PrrmttR.lerme g Issuing Authority(circle one)- 1. Board of Ilrulth 2.Building Departutuat 3.City/fown Clerk 4. Electrical inspector 5. Plumbing timpeetor 6.Other ._. Contact Person: Phone tl: CITY OF SOU Etit, ILuSACHUSETTS 3 4i BL•ILDLNG DEP 1RT3,0NT 120 WASHLNGTON STREET, 3'FLOOR T FL. (978) 745-9595 KIMBERLEY DRISCOLL F.A-`t(978) 740-9346 NLAYOR T koxu ST.PIERRE DIRECTOR OF PLBLIC PROPERTY/8VUML\G COSL\IISSIONER 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 1 t 1.5 Debris, and the provisions of MGL c 40, 5 54; Building Permit f# 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: C 1 of v GCS. name of hauler) The debris will be disposed of in r r S(s C (` t (name of facility) (address of facility)--- signature of permit appl an` t / I date dcbnsatt d•x eebu: \A eA't 'in r r 1 i i . - _• - 1 . - r - r .T. _ _ _. _. - r ,. 1 _ _I r f-._ - .r l I i , + Z • I t j � 1 I MA•�RVI. ' 2xts;la� l � I I � r I t i • T � ' 4 } eco IF doo {{{ , S F -I. _ }. . .l ..+ _,. . -- .+.._ _ .., +- .t 1• +. .�.. _;. . - }. -I ._.r--_ t _t �. _ -� Ito O.G. _ T 4 I • t i 1 !! t I . D s . o ,e o y a o• o 0 o w S O o. O u p ,0 D t- '•D 1 i f : { t - � a _1. - I �••� I NO > .0 � 0 e 0 dO 0 J0 �0�:•.•P S:�R 00000�Dp-0 Lp J• 1 'QeWAA�l Z ---' � , D .. .. _ :.. ». t : . t.. .. r F #- a -, t � .:. # . 4. — - -,' .} 1. .:. . _ , — + +L p1GN•b'@ bxl6 vl,�lr � 6 ! I I J— L 71. ` Offic of Consumer.Affairs&Business Regulation- V E'HOM .IMPROVEMENT CONTRACTOR Regist.ration: ,073271' � Type: Expira.eon kO0 014 - Individual f �_ A MO'DI,CA .3J.- f _ Ilia'`t STEPHEN MODIrC �� - re-� 20 ORCHARD RDA SWAM PSCOTT, 0 01907 Undersecretary { License Statu1 Address Name License Number License Type SWAMPS OTT MA 01907 MODICA STEPHEN A CS-06I.448 Construction Su ervisor ctive , 1 i " I ci p �f os 9 PROPOSAL Page#—t_of d pages STEPHEN A. MODICA Carpenter/ Contractor 20 Orchard Road Swampscott, MA 01907 781-724-8197 or Imodica@verizon.net Proposal�t�t�e Tc—� Job Name Job# ff�� Address Job Location Date Date of Plans Phone# Fax# Architect 97 - VW 7 t/ We here, by submit specifications and estimates for: / 611, ill 6,0 7 1�_ �� � - d y w / , 60 We propose hereby to famish material and labor—complete in accordance with the above specifications for the sum of: Dollars with payments to be made as follows: I IS --�' 1 /3 VG zt,.a N Any alteration or deviation from above specifications involving extra costs will Respectfully submitted: be executed only upon written order,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments Signature will be made as outlined above. Date of Acceptance: A-NC3919/T-3850 GENERAL PROVISIONS 1. All work shall be completed in a professional mauner and in compliance with all building codes and other applicable laws. 2. To the extent required by law,al4 work shall be performed by individuals duly licensed and authorized by law to perform said work. 3. Contractor may at its discretion engage subcontractors to perform work hereunder,provided Contractor shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this Contract. 4. Contractor shall furnish Owner appropriate releases or waivers of lien for all work performed or materials provided at the time the next_periodic payment shall be due. 5. All Change Orders and/or Additional Work Authorizations shall be in writing and signed by both Owner and Contractor. , 6. Contractor warrants it is adequately insured:fgr injury to its employees and others incurring loss or injury as a result of the acts of Contractor or its employees and subcontractors. 7. Contractor shall,at its own expense,obtain all permits necessary for the work to be performed. 8. Contractor agrees to remove all debris and leave the premises in broom-clean condition. 9. In the event Owner shall fail to pay any periodic or installment payment due hereunder,Contractor may cease work without breach pending payment or resolution of any dispute.Failure to matte payment within days from the`due date of payment shall be deemed a material breach of this contract. 10. All disputes hereunder shall be resolved by binding arbitration in accordance with the rules of the American Arbitration Association. 11. Contractor shall not be liable for any delay due to circumstances beyond its control including strikes,casualty or general unavailability of materials. 12. Contractor warrants all work for a period of days following completion. Note: This form is not a substitute for the advice of an attorney.Legal advice of any nature should be sought from competent, independent,legal counsel in the relevanu jurisdiction.Absolutely no warranties,are made regarding the.suitability of this form for any particular purpose-