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32 SABLE RD - BUILDING INSPECTION The Commonwealth of Massachusetts OF Board of Building Regulations and StanCp[C)�EIVED CITY M Massachusetts State Building CtiMP NKINQL SERVICALE ES SdMar Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-FamilyDwelfMAUG 2 b AID 58 This Section For Official Use Only Building Permit Number: Date AppY d: Cr Building Official(Print Name) Signature Date l SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a 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 fl) 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 OWNERSHIP'' 2�4 ,QA R'ecord:L.f;�O�`/ J/rpLEM Iq14 L Name(Print) City,State ZIP 'al s/w r= #L17 Z04W94-?1- No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK;(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ S ecify: Brief Description of ProposedWork2: zoe SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ V 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other-Fees: $ f izl� 4.Mechanical (HVAC) $ .List: / t 5.Mechanical (Fire Suppression) $ Total All Fees:$ i Cheek No. Check Amount: Cash Amount: 6.Total Project Cost: $ ��l'/(/ ❑Paid in Full ❑Outstanding Balance Due: bV rn�tL�o s131 SECTION 5: CONSTRUCTION SERVICES 5.1 Con Supervisor License(CSL) e s �w t"XL License Number 7 E imuo ate ame of CSL Holde'r / �- List CSL Type(see below) No.and Street ' Type Description. /.,/m 1 f� Q�/O U Unrestricted(Buildingsu to 35,000 cu.ft. �J' Z_/ 7 R" Restricted 1&2 Family Dwelling Cifyfrown,State,ZIP M Masonry RC Roofqg Coverin WS Window and Siding 9 �n M� SF Solid Fuel Burning Appliances p�.(� I Insulation Tele hone Email addfess w . D I Demolition 5.2 Registered14 Home Improvement Contractor C) Co?^'t � 14_°.1✓!t HIC Registration Number Ex/ffatie6 Date HIC Company an�oI egistrant Naiqe Strygt i ei r1G 2 Email address /`a�7 Ct own State,ZIP ! O Yc, 7 Telephone 1 C 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 UE 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. eA2 k(2 M416eY oPE - Prmt Owner's Name(Electronic Signature �I ?5te SECTION 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. rre7w 1) &n Ai Y o Print Owner's or Authorized Agent's Name(Electronic Signature) ate NOTES: . 1. An Owner who obtains a building permit to do his/her own work,or an owner who hives 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 �i�vw.nrass�ovloca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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" The Commonwealth ofMassaehusetts t Department of IndustrialAccidems, I Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia rworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FH,ED WITH THE PERMITTING AUTHORITY. Applicant Information Please P nt IR21bly Name(Bwiness/OrganiTatior✓Indidividual): / Address: City/State/Zip: Phone#: O o/ r4. e yo w employer?Ch k the appropriate box: Type of project(required): 7 employer with _employees(full and/or part-time).' 7. ❑N Construction 1 am e,sole proprietor or paMership and have no employees working forme in $, odeling my capacity.[No wmkeis'comp.insurance required] . Q I am a homeowner doing all work myself.[No workers'comp.insurance required.], 9. ❑Demolition 10❑Building addition I am a homeowner and will be hiring contractors to conduct all work on my property. I wn71 ensure that all contractors either have workers'compensation insurance or are sole I I.Q Electrical repairs or additions proprietors with no employees. - 12.E]Plumbing repays or additions 5. 1 am a general contractor and I have hired the sub-ntactors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance, - &❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such tContractors 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. /7 Insurance Company Name: Policy#or Self-ins.Lie.#p: �y/7�n© �J �9 Expiration Date: Job Site Address: t%off-- O�G P` City/State/Zip: 0 ��C2 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine 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.A copy of this statement may,be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the p 'ns and penalties ofperjury that the information provided above is true and correct Signature: Date• Phone#: Official use only. Do not write in this area,to be completed by city or town ojficiaL City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pemnipicense number which will be used as a reference number. In addition,an applicant that must submit multiple perdt/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017. Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia OTY OF SALSA MASSAaiLJSE TTS BvnAIIVG DEPARTMENT 120 WA9HINGTONSMREET,3IDRom 7kL(978)745-9595. %IIv18ERLEYDRIS FAX(978)740-9846 �LL MAYOR TrIOMAS STAEM DIRECTOR OP PUBLiCPROPERTY/BuwHgG O xagssiomR 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.S Debris, and the provisions of MGL c40, S 54; Building Permit g is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: t= P f 9po (name of hauler) . The debris will be disposed of in: (name of facility) PD (address of facility) Signa a of applicant Date Home €improv®re�esa!_�pr MANH HOME MPROVEMENTS HOME IMPROMENTS CONTRACT Homeowner Contractor Information FStreetrard Land MANH HUYNH dress: Business Street Address: 26 Spencer Street Rd.n State Zip Code City/Town State Zip Code MA 01970 L nn MA 01905 Phone Evening Business Phone Evening Phone 1907 781-632-0577 ddress(If Different From About) Contractor's Name: Manh Huynh License#CS 99237 - fully insured WORK TO BE PERFORMED AND MATERIALS TO BE USED Remove old window then install new one and replace complete finish around outsi]]downto Install the gutters at the top of the window. Material and labor cost $1,000.00 (window by owner) Build new sunroom around 100 sq. ft. and install new window and door. And comp outside sunroom. Material and labor cost $8,000.00 Build new deck from the backdoor to the backyard around 200 sq. ft. with stairs go landing. Material and labor cost$6,000.00 Total material and labor cost$15,000.00 Upon signing the contract $5,000.00 Date....................... 1/2 OF project the contract $5,000.00 Date ....................... Upon completion of the contract $5,000.00 Date......................... SIGNATURE Do not sign this contract if there are any blank spaces Identical copies of the contract should go to the homeowner and the contractor. Homeowner's Signature:2Qh& �ontractor's Signature: Date: D�� Date: 6gc��f i Massachusetts -Department of Public Safety Board of Building Regulations.and Standards Construction Supm isor License: Cs-M237 MANH TgpyNH •�` 1 ''�:• �•, i Y. Lynn MA 01905� URI' m Commissioner Expiration 04/05/2016 Office of CoosumerAt7���r��rys� Bu81sRto�u<ae/fi u ME IMPROVEMENT CONTRACTOR istrehon: 150405 .. IF i2bon -r3%28/2016 T�Pe:. ` MANH T l�14� , Individual RUONG HUYNH�L s'. MANH HUYNH `-;,�'-L A - 26';?PENCER ST13EE7., c' LYNN, MA 01905 ' Undersecretary is / 0 �� .. . s � I U 1 a � ��z