22 SHILLABER ST - BUILDING INSPECTION a
'Y7 C*,-4� /13
/ �� _ � --- I'hc C'onununsccahh of Ibl:usachuscits
, Board of Building Regulations and Standards CITY OF
W sr \Ltssachusctts State Building Code, 780111
,L:,•• /.ILu''0//
Building permit Application To Construct, Repair. Renovate Or Demolish u /(,•rim
Unc-or ruvt-Fumils Divellm.q
This Section or O •ial Use Onl
Building Permit Number: ate Applied;
Iludding Ullieial(Prins Munc) Signature Uute
SECTION 1:SITE INFORMATION
I,I Property Address: 1.2 Assessors,Alap& Parcel Numbers
22 Sh-, ilo"V— 'S —
I.la Is this an acre ted street? es no Map Nunther Floral Number
1.3 Zoning Information: 1.4 Property Dimensions:
Luning'District11nit cd Use Lot Area(sq III I'mnlage III)
1.5 Building Setbacks(R)
Front Yard Side Yams Roar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.1.c. 4o.§S4) 1.7 Flood Zone Informatlont 1.8 Sewage Disposal System:
Public(3 Privula❑ Zone: _ Outside Flood Zona?
Check ifaO Munieipd O On site disposal s)item O
SECTION2. PROPERTYOWNERSHIPs
2.1 0 nett qf Record:
rr/Stt�e- Ci t l Sat MA 01 �/ "7 �
N;una(Pont) City.Slate,ZIP
7-2- Ad(Aer- St 611 470 U77
NO.and Strews Telephone F.muil Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Feasting Building❑ Owner•Occupied O Repoirs(s) O Alteratlon(s) 0Addition ❑
Demolition O Accessory Bldg. ❑ Number of Units_ Other O Speeily:
Brief Description of Proposed Work':
t / .3 U AV Vq r f,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
I L lbur and.\l;rterialsl Official Use Only
I. Building $ �y �.� I. Building Permit Fee: $ Indicate how fee is determined:
l '. Occirical $ 1J Standard City.Tussn Application Fee
❑Total Project C'ostl(Item 6)v multiplier _ _ x I !. I'lunlhing $ ?. Other Fra: $_
J. Mcch,utical IIIC \('I i List:-_ —_-__ bb
�u +vcssionl rotal \11Fces: $ --- —' .._ .. .... ._ . .
r, Foul project Cue#: i �/ �O (heck Nu. _. __( Ilcck.\main: . .........0 a. h \mmmc
❑ P.lid In Full ❑UulsCmding B.tl,mce Due:
��� 7' >
,
tiF:("I'IUN S: ('ON,I'RI C'flf)N tiF.RVI('F.S
5.1 Con
structimt Supers isur License(C'til.) ! S-.2, J
I icuroe Numhar I viniholl 1 ;Ile
�0� �r 2✓CQ �
N;nue ofCS1. Iloldcr 1 1st l'SL pe Vac
r y - I)cscriplion
_192Li1/L�hS!
ry
No. and street /� �U l4trcauicicJ IIIuilJin�s 1i to ls•nt)t)cu. it
Q �— Q -/ Slaw crud Ia'?f.unil Dt,cllin
� >I !lesson
Cigill,,s n,st.ue.Lll ----
KC Koolol Corm
µ'S µ'inflow•.uld Sidin
ry�p SF Solid Fuel Iluminy Appliances It)v3L S�✓V I Cej I I moiun
O h:maii:IJJms /t')at <c D Dumolitian
l'dc bona
4,2 Registered llume Improvement Contractor(H
U�Q Cr2lr to J LLC IIIC Itcgistratiun Number liq+inlliun emu
I IIC Coalpan) ;unc nr I IIC Iteglstrunt Nr mu n �r LJ S e SP r VI aA � R wlk('
"" r- to Mfg -�(Y'= !:mull aJJM1.rs
Na. wIJ 51nwN� a 1-- —
Cf !Town,State ZIP Tae hung
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L,a. 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•.... .....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
L VIbV"sp— 14V-0 j
to act on my behalf,in all matters rel Live to ork author' ed by this building permit application ) ' Z 2
0 e le l
Dale
print uswer's Nwna( 'Icclrunie Signature)
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 informatiun
contained in this application is true and accurate to theXbtof my osvledile and understanding r 7
LJe- ko Ott- S__Q✓ 0
I'ri111 0uncr'+or:\uthorucJ Agent'+Nunw 1 Flecnunle.�Ign;ulucr
Data
NOTES:
I. An ostnerwho obtains a building permit to do his her awn stork,ur an ownerwho hires an wlrcgistercd contractor
(nut registered in the Hunle Inlpruvenleot Contractor(HIC) Program),will no have access to the arbitration
program or guaranty fund under\I.G.L. C. la_'A. other important information on the HIC Program can be found at
N,tN a�.l" ��, ,•, I Information un the Construction Supervisor License can be found at,,+t^ III1`1 o:'t •Ill.
1\hen substamial work is planncJ, prutiJe the inlurmation below;
f. Iloor area I iy. tt.l - _--_.._I including garages. linished basement anics.decks or perdu
flabitablc room count -
Gn,ss iMng area l sy. III I .—... .._ \anther oI beJruouls _
\umber of lircplacei
\unlhcral'balhroonls \untherofdccks s: parche
I\pe of hc.uing i)itcnl
ltpcn
I\I":of:,,ol ng it uem
PncA,tcJ
\ ..I�q.11 I'f�,I¢❑ 1,111Hre 1',Nnay'e 111:1\ he uhtliuncd lilr 'total I'rojed Cots"
cl-l'Y OF S,ULE.NIr NWSACHUSETTS
BUILDING DEP.IUMEINT
120 Al NSHLVGTON STREET, 30 FLOOR
TEL (973) 7,<5.9595
F.U((979) 740.9844
:<I.%IOE,'LIEY DRISCOLL
A{YOR T}tOSL\3 ST.PIERAB
DIRECTOR OF PL'OLIC PROPERTY/9t:ILDrNG COSLNIISSWNER
Workers' Culnpensatlon Insurance AlTfdavit: Builder.�/Contractorv/Electrician.,VPlumbers
Itoolleant fn[nrm•rtlnn PlcaYe Print Luclhly
V;IInC Innein.,t,urg.7ni»run.lgnd�iv�idu.tn:
Address: VV 10 hVOV-1,li+
City/State/Zip: ( (]la6�oneM
"1re you An umplayer'r Check the appropriate boat Type of project(required):
I. I a a employer wish general�_ ;• ❑ I a ageneral contractor and I
� irs anlpinyera(ILII antUorpart-lime).• have hired the wbcanlraclors 6. ❑New crosaWction
2.0 1 am a solo proprietor or partner. listed on the attached.rheur. t 7• ❑Remodeling
.hip and have no employees These sub•confractors have I. ❑ Demolition
working for me in any capacity, workers'camp.insurance. 9. El Building addition
(No workcn',camp. insurance J. ❑ we are a corporation and its
rvquired.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 can a homcuwnur doing all work right urexamplion per MGL I I.Q Plumbing repairs or additions
myself.(No workers'sump, c. I52, 41(4),and we have no 12.C] Roorrepairs
imurancereyuired.1 t employees. (No workers' I3.❑Other
comp insurance ruyuite
\ny appik:ue aW clnvlta box 41 Mors aw fill uos the wcsiao Wow showing their"ton*eempenudun pulit.y 1,,nJMan0n.
'I hvnuuwnen uhu•uhmil WE rlfldavil indlealne they ors doing all wrk and then hit*uuride"" IN"mdn 1111114 1 new allidavil indiaine W)L
t'wtrytun that thtsk ibis boa Mug atachue an addulutud.hnal.huwins the nwev arthe subevairscwtv and ihalr workers'comp,pulley inruenuaan.
/urn an rnrpluysr rhurJs pruvlding workers'compeissallen Glsuruneejbr my employers• Seluw/a r/fe policy and job site
inj'orurullnn.
In,urotce Company Namr�....�/IlthOh
Policy J ur Self-ins. Lia. d: W -007y�1�0--t/�—(Z012 Eapiralion Date:_. S� 7
Z2 A I I Lo � Alp
JwbYila,�dllrc'Ya: L R � CityiState/2;ip;�s�.� 6V1 MA 0
.\nacb A copy or the workers' compeneatlaa pulley deciarAllan pay@(showing IM Polley number And expiration data).
1:liluru w wi;uru cuvera,a u required under.Section IJA of bIGL e. 152 can lead to the imposition oferiminal penalties ore
line up to 5I,500.00 undlur mie•yeir imprisonment, 11 well as civil panallias in the farm ofo STOP WORK OROEA and a lina
ar.ip fo 5230.(10 a Jay iyainst the violator. Ile advi.ted that A copy If this,talvmeni may be iurwarded to the Oltieu of
k lvc,tiylliutt.'t of tits r)L1 for ioiurluce eoverngc verilic.11iun.
71,1ahvrrby rrrri/y nu ♦ du uiu und/rn Wer•,/perjury r/tul tiro in�ururur/car pruridaJ uGu r ie rr anJ rarrrrt
U//it'i,l me,ndy. /7.n„r tense itt INY Bran. ra.}r cumyl♦r✓J Sy illy r f ru,.n
City ,tr I'uwa: .. _. i'crmit/l.kcnte d
L.uin'd.\whorily (circle one): ..—... . . ._
I. award h !. Ilnililing 001).1rhuenl I. I ily�'I•nwIt Cterk 1, lilcetric.'I fn pcc tnr i. I'InmDin;; Intpectar
)I lter
l.nuld_I 7'ertnn.__.__.___
C(TY OF S'VZ%f, AUSACHUSETTS
dLLEDLNG CEP.1RTJtE`T
1'0 ',VkJHNGTON 3TX9jr, 1"FLOOR
112L t978) 743-9599
KIMBU r BY ORUCOLL FAX(173) 1 f4984
1L1Y01! rko-%W ST.PMx"
CrMUTOa O'PL SLIC PROPARTY/BCMDCjU CGSL{1113(ONEx
Construction Debris Disposal Aftldavit
(required rot sU demolition and renovation work)
rn accordance with the sixth edition of the State Building Cade, 790 CbfR Debris, and the provisions of,MGL o A 3 54; section I It.J
Building Permit M is issued with the condition that the debris resulting from
III, 3 I JOA.
INS work shall be disposed of in a properly licemed waste disposal racility as defined by NIGL c
The debris will be transported by:
�l Gi
L GT((p� f /
(name ul hauler)
The debris will be disposed Orin
(�,ma of— rjv,t w --
t,�aref, or'a„t„Y1
u rna tau ;ermtf rpphc,nt
Page No. of Pages
�tir0�10���
Insured Litehouse Services
License # 95280 Litehouse Services 67 Monument Avenue
H.I.C. # 142824 Home Repairs Made Easy Swampscott, MA 01907
litehouseservices#hotmail.com
r
Bob Pierce 781-864-5238
PROPOSAL SUBMITTED TO PHONE DATE 1
STREET rj JOB NAME
cITY,STATE AND zl CODE JOB LOCATION
IA Q iG
'- APPROX.STARTING DATE JOB PHONE
We hereby submit specificationsand estimates for: ,^
r
f i Y Gt"1 1 i "t ktJ
r
I'J
!!
")�/l Propage hereby to furnish material antl labor—complete in accordance
with
wi thabovespecifications,ffor tuhe sum
/C�ZVha—Dbllars $ 10
—
Paymenj�6 he made as follows:
1/3 down, 1/3 middle of job, 1/3 upon completion
All material is guaranteed to be as specified.All wait,standard to be completed in a workmanlike manner Authorized /�nq
according to andard practices.Any alteration or deviation from above specifications involving Signature I�—'{I• Y '
eAds costs will be executed only upon written orders,and will become an extra charge over and
above the estimate.
Note:This proposal may be
withdrawn by us if not accepted within days.
i
I
ACCP-fltanEr Of 10178p0081 The above prices,specifications and conditions are —
satisfaciory antl are hereby accepmd.You arc authorizetl to do the werk as specifiatl.Payment Signature
volt be made as outlined above-
1 i
Date of Acceptance: i \ � I � p'�)1, '� Signature
t
�uvz/vvz
CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE L4 ISSUED AS A MATTER OF INFORMATION ONLY AND CONF O4�MwoorrvrYl
CERTIFICATE DOES NOT AFFIRMATNELY ERS NO RIGHT$ UPON THE CERTIFICATE HOLDER.Z20,HIS
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
R NEGATIVELY AMEND, IXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.I IMPORTANT: C the certificate holder Is an ADDITIONAL INSURED,the olic les must be endorsed. If SUBROGATION IS WANED,
the!eons and conditions of the pocky,Certain ent( policies may require an endorsement. A statement en this eartl0cate tloes not colNer rights to the
I certificate holder in lieu O(such endors s), subject to
PRODUCER
CONTACT Christo h
Farqu}lar 6 Black Insurance Agen PHONE p @rnn�y
85 ExChan a Street �� nc. (AK.[to K.I. (781)599-2200 I FAX ---
g - Suite 101 E-Maa tTsi�,ei_
L
AROODfiESS:Chri51@FandBZne
INsuREo - DUCER uran fA(c.-NPI`_.--.. 39•R
P a0.aom..-_ MA 01901-1475 00031841 �T
—.___...__...
INSGRes S AFFORDING COVERAGE I
IN9UgER 4:Sat:e ty Inaura os, NAIGN
Litehouse Services, LLC 6 INSUReRDAssociated Emulovars Insvranc 9454
7 Monument AvenueR0959
8wampsoott ".. . . . .. ..
MA 01907 INSURER E: ,
COVERAGES HIS IS TO CERTIFY THA CERTIFICATE NUMBER:TataD qg gNl� RER
TT THE POLICIES DP INSURANCE LISTED BELOW HAVE BEEN 3SUED TO T'NE INSURED NAMED ABOVE ':THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY RECUIREMERA TERM OR CONDITION OF ANY CO REVISION NUMBER:
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO
EXCLUSIONS AND CONOMON CON IE OR OTHER DOCUMENT WRt{ RESPECT TO
S OF$UCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, WHICH THIS
TYPE OF INSURANCE. - ._ . IADDL SUBRI ., ALL
THE TERMS,
'GENERAL LIABILRY POLICY NUMBER 1 p C EFF POLICY EItP _
D
COMMERCIAL GENE I UMna -
RAL UABILRY EACH OCCURRENCE is
CLAIMS-MADE r1 OCCUR i DAMAGE TO RENTED _
MED EXP 1pin are PRsanl t . .
I j I PERSONAL t AOV INJURY g GEN'L AGGREGATE LIMIT APPLIES PER-
0- 1
O- I L GENERAL AGGREGATE $
POLCY I LGC —
AtITOMOBILE WBILfTY PRODUCTS-COMP/OPAGG 11
t
ANY ALTO (EA M SINGLE LIMB E A ALL OWNED AUTOS I I620JO34 L I I I
IILy'X SCHEDULEDAVTOS L/12/2011,11/12/2012 DORY IµIURV(p�.P��l s
^I HIRWAUTOS BODILY INJURY(Pg,geypppll't -- 100,000l
I I I pROPERTYDAMA 30O,00G
X t y
NON-OWN AVTOS i(P0 Recidenl) ._.. 100,000
uniRvetl mDldial eranGnetl .. .t_.
UMBRELLA OCCUR LIAe I __ um>whaurert lipmnel .. .t.
i '
EXCEESUAe CLAIMS•MAOE EACH OCCUR
RENCE t
OEOUCTISLE AGGREGATE
S,
13 WORKERS COMPENSATION t .. -
ANDEMPLOYERS.LMILnY E _.. .
ANY MOPRILTO"ARTNER)EXELUTIVE YIN WC STATt} OTH-I
OFFIGERRJEMMR E%CLUDEO! NIA X TOm'UMI ER
o(Mamatmy In M) cC5009958012012 F EACH ACCOI t
E9ECRI�PT ON�nnP OPEM'hoNS ealow /7/2C12 l4/7/2013 ___500,000
E.L DISEASE-FA EMPLOYE s 500 0
E. DISEASE-POLICY LIMITS 0 000
DESCRIPTION DF OPERAT10N5l LOCATIONSIVEHICLES (AI ACORD ter,ACtl111o�I Remarks 9eheEule,Bmare spacakroWeRd)
CERTIFICATE HOLDER CANCELLATION
(7B1)596—Q590
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Swampscott ACCORDANCE WITH THE POLICY PROVISIONS.
22 Monument Avenua
Swampscott, MA 02907 AUn10RIffDREPRESENTATIVE
Tan Cruz
ACORD 25(2009109)NS025(t ®19BB-2009 ACORD CORPORATION. All A h r
rm9osl The ACORD name and logo are registered marks of ACORD 9 f$ eserved.