5 SCHOOL ST - BPA 12-799 , a
I'he C'onunonweal(h of Massachusclts
Boardufl)uildiog Regulations and Standards Cl l'1 OF
s /9 kfassachusetts State Building Code, 780 C'MR SALEM
Re I
Building Permit Application To Construct. Repair. Renovate Or Demolish a
One-or rivu-Fmrrilr Du elliop
This Section For( lcial Use Only
Building Permit Number: ate Applied:
[Wilding 0111cial(Print Mum) Siµnatu Dole
SECTION I:SITE INFORr*IATION
1.1 property Ali less:�� � 7/TOOL 1.I Assessors blap S Parcel Numbers
1.la Is this an acce ted street? es no 16hrp Number Purcell Nuntlnr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Fmnlage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yurds Rear Yard
Required I'mviJcd Required Provided Required Provided
1,6 Water Supply:(M.G.1.c.40, §54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Ihrblic❑ Private❑ zone: _ Outside Flood"zone?Check if esO Municipal On site disposal s)xtan ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
M R f
Munc(Print, I IG / ('it)•,Slab,l.IP
rare S 3— I�i 611 �'t� �G[�n�l) rnU� Inal rr)u
Street r HUail Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(Check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) C1 j Addition ❑
Dentulilion ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: EfIL4LI&I
Brief Description of jrqposed Work`:
b lC&
SECTION a: ESTIMATED CONSTRUCTION COSTS
Ilcnt Estimated Costs: Omclul Use Onl
(Labor and .Materials) y
1. Building Stotl I. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S n ❑Standard City?uvvn Application Fee
❑Tutal Project Cost r(hem 6)x multiplier _._ _ s
1. I'lumhi°g S 2. 01her Fees: S
J. .Mcchanical Ill\ W) i List-
\Icch.wical I hrc IFI't�:,, Ail
Fecs: S_
` Check No. ('heck Amount: _ (',uh \mount:
o Tula) Project Cush 3 fU's 0 p;tid in Full 0 Outstanding Hal:utce Due:
lit
SECTION S: CONS'1'RIIC rION SEMI ('F.S p
5.1 ('unstructiunSupcnisurI.iceu`s`e(('St.) /C Q4ko3 _ A. -
.. ._JC!L�f^{L-_.-. .�!L �N.. 1 icLenJ- Nlniii)her I �oral m Pule
N:unc of l•SI. it it•
r `pI} (� IisCSI. I)Pe(see
helowl.__._1L_._.—.._
I[IS _. d--- .._-------- '11 pe Description
Nu. .ut�\heel
`` it I4treslrieleJ I Iluildifts on rat 15,11110 cu. Il.l
it Restricted Ia? F.unil Dwcllin
Cilsi l'own..Wate.LlP .St \lasun
R(' Ratin Co"
R'S N'indnw:mJSiJin
SF solid Fuel Iluming Appliances
�(� I�L'11uN1�JiT2 A.11 -CO I Insulation
l'alc hone Finail address D Demolition
5.2 Registered home In )ruiivvAe--/mI,etntt Contractor(HIC) 6 3
CATN�I � q N — IIIC'Re istruliun Numlwr li tiro on l e
IIIC'C' Inpmq me r,I IIC Ito
is rant amu GI I try
4� r.111s r �.� r 1 /} C i
N . and S t �la t ()Iq lei SO I I� imuil address
OD
City/Town) State ZIP rele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. I52.1 25CM)
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 Aflldavit Attached? Yes .......... ly No...........0
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 Ownei s Name(Electronic Signature) Date
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.
Print Owner's ar:\ulharireJ Agent's Nanwt(FIVOrunic Sigmuura) Date
NOTES:
I. An Owner whu obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(tut registered in the Home Improvement Contractor IHIC) Program), will no have access to the arbitration
program or guaranty Iund under I.G.L. c. I4]A. Other important information on the HIC Program can be luund at
•h.I Information on the Construction Supervisor License can be found at o�%- 11I.N: g.n Jps
2. When substantial work is planned, proside the inlurntatiun below:
rota) flour area(sq. li l . __.._t including garage. finished basement attics.decks or porchi
Gross It%iog area l sq. ll.l ___.. -- Habitable room euwtt
\umberoffireplaces _.. .-_ ._. ..-.. _-- Nuntherol'hedntoms .. .. - . .
Number of hathrounts Number of half baths
I)pc of heating sysicnt - . . Norther ol•decki, porches
I)lit:lit:al•:ooliog i)item I!ndoied ..()It en
i
1 "IoLll Proiv" Square Footage Ioay he substituted Ibr"tonal IlrojcclCost"
CITY OF S:U-F.ct, NWSACHI;SETTS
+ ' BUILDING DEP.\RT>iENT
i
120 WASHNGTON STREET, 31O FLOOR
�,•�" lit (978) 745-9595
F.iIc(978) 74Q9846
M.NIISERLEY DRISCOLL
IN LAI.YO Z T tionu ST.PiE.&R8
DIRECTOR OF PUBLIC PROPERTY/aurw c,Co\L%us5iONER
Workers' Compensation Insurance AtTidavit: 0Uilders/Contractors/Electriclans/Plumbers
4lllilleant Information { A rn• Plearce Print Le�ihty
.N; inc Innnin.Is Urg,lmrati'n lndividwJ): C� I �AL- t'S
Address:_ ht, udhi; qT . -42
CilyiStatcyZip: YJOLL HA DMS Phone
Are you an employer!Cheek the appropriate boxi Type of project(required):
I.❑ 1 am a employer with 4, ❑ I an a general cunfroetot and 1 6. ❑New construction
ymplaycea(fLll and/or part-time).• have hired the su!}eamncWrs ��/
2. lam a safe proprietor ur partner- listed on the attached.rhecL t 7• U RemadNing
.hip and have no employees These subcontractors have V. ❑Demolition
working for me in any capacity. workers'camp,insurance. 9. Building addition
(No workers',comp, insurance 5. ❑ We ass a corporation and its
roquirud.) officers have exercised their 10.0 Electrical repairs or additions
J.❑ 1 am a homcuwncr doing all work right urexemptiva perm L I LCJ Plumbing repairs or additions
myself.(No workers'Gump. C. 152, §1(4),and we have no 12.E Roof repairs
insurance required.) t ompluyces. (No workers'
camp, insurance rr quircd.1 13•0 other
•,hny applkwn doe Omits but el mint Aid fill uul ih•WOW below.howins chair"ken,compenudun pocky inMrmmloa
'I LvrWYwftml who Itall"1I this rtndavlt indIcalna they its,doing ill work and Thal hit*uugide eentmaea midi Submit a new aattJaril indiaine.ace
t'muxtun than chap this box man aa da.h an 1"ll.roe.hsl.huwiny the nwno of the rvbauntntlert and their workers'ramp.paltry Infomudee.
f am all eurpluyer r6at/s provfdlnX 1 orkers'camp rnsarlun bunranae for my emp/uyews Belo/s the polky and Jab site
h1forurudon. /
In..urmce Company Name: r7�,�/�� C�/C�_rP- _. h G
Policy, 4 or Scif-its• Lie, N: S.D/1�1 I)f 06 JC1 Expiration Date: j
lob Site Address: _� I I�sd f� Cilyistate/2ip: 01�I n-70^
AUacb a copy of the workers' compensation policy declaratian pi its(allowing the policy number and expiration data).
F iiluru W sectiru coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ors
rirc up to 11,500.00 aml/ur one-year imprkniamenC as well is civil penaRics in this form ufa STOP WORK ORDER and a lino
of till fa S2A.00 i Jay Jgainst the violator. Ile advised that a copy of this.utvmcnt may be furwardcd to die 011icu of
to\'Citl g shuns of die MA Gar insurance coverage veriticaliun.
/du/rrrrby a r' uuJrr dsk paint usl prnaltle.r ufperjury that the lnfunrrur/on pruvlded'bave is tr ♦raid eorrece
,I Data: a
1I/jia'iu!nee only. /)•r rant rorile in d�ir oars, N he rump/rA'J by rily ur lawn nfflr/uL
Gay-it fawn: . _. __ I'crmitil.tecate d
Lluiar.\whorily (circlo ww)t —._. .. _..-_ . .
I. ISuard al IDeahh S. IIuilJlnq Uep.trhncnt i. ( ityi 1'uwn C'Ierk J. Eftetrlc.d Itivectnr i, hhun Ding fatpeetor
G. Ihlrer
L unl.tal 1'er aul:
nsu-1 ) \ UIIS 1 l4,ecw
Office o o 62 nsumer, ans mess egu ni
HOME IMPROVEMENT CONTRACTOR
Registration 170344 Type:
Expiration 10/12/2013 Individual
CA _ L GLYNN r_
CATHAL GLYNN',
46 WALLIS ST#2
BEVERLY, MA 01915 Undersecretary
-;Massachusetts- Dcp:utment Of Public S;tfctc "
Board of Builtling Regulations and Standards
LOf Construction Supervisor License.
License: CS 87423 ^- `•^^""'"
i
CATHALM' GLYNN
46 WALLIS SST#2
BEVERLY, MA01915
o�� if•/��� Expiration: &13i2013
('ommixsiouer Tr#: 5784
CITY OF SM-EMs Akss.,CHUSETI'S
2LILD04G OEP. MONT
110 V -UNLYGTON ST1tW. 1iO FLOOR
I'EL k978) 745.9599
K1113F_RI EY 0PUXOLL PVt(978) 7 9846
MAYOR T}tOmU ST.PMUS
DIXECTOEOPPLet'CPROPERTY 8VMDLYGCONOIISSIONER
Construction Debris Disposal At'ildavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cade, 780 CMR section 111.S
Debris, and the provisions of MOL o 40, S 34;
Building Permit M is issued with the condition that the debris resulting from
this work shall be disposed of'ina licensed waste disposal racility as defined by ,b1GL c
111. S I JOA.
The debris will be transported by:
Ski_F
(name ur•heuter)
rho debris will be disposed of in :
(non�}e of rauilily) 1�
1� Yl,r�krnll C�d Sc,IQ r� .
drer, orfud,�Y)
utnaareor;ermit Bunt
,Le