27 SHORE AVE - BUILDING INSPECTION a
The Commonwealth of Massachusetts q ' '
Board of Building Regulations and Standards ; � Fi
U'11 Massachusetts State Building Code, 780 CMR Revised Blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolishil CT I T A`` 1
One-or Two-Family Dwelling
^^( This Section For.Official Use Only
Y Building Permit Number: Date Applied:
Building Official(Print Name). .- Signature - - Date
SECTION l:SITE INFORb1AT10N
LI operZ ddress• 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted sttree�t?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Zoning District Proposed Use Lot Area(sq fl) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Rcquircd 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check If es❑ p Po y
SECTION2: PROPERTY OWNERSHIPU
2.1 Owner of R ord:
5Jimi • HA GlG70
I�thme( ant)- City,State,ZIP
o7R 9-7% —g6
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(chec all that apply)
New Construction❑ Existing Building❑ Own Occupied Repairs(s) Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed\York=: 6w h
CSC - Viet-o
P��tti!mot-'v�F,.� -➢ >�J_�rW�1OV/r.P �-��4r_1ro1 NCW p�.t@si�a]
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 5 �� 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard CitytTown Application Fee
2. Electrical S l \000 ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing $ 31000 2. Other Fees: S n7�
4.Nicclumical (FIVAC) S 1% 000 List:
5.Alechanic:d (Fire S Total All Fees:$
Suppression)
Check Na._Check Amount: Cash Amount:
6. Total Project Cost: S Lb 0616 ❑Paid in Full ❑Outstandim, Balance Due:
ur N1I�1r_EG IQpz+�
�� ob��
1
s
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 164 87 Zg ZOI
,fJ .. b V✓N License Number Expiration Date
Nanic of CSL Holder List CSL'rype(see below)_
22 Gry tN�e Jrir{(d' Type Description
No.;md Street -
.,1 U UnrcstrictcJ(Buildings tip to35,OW cu. tt.
� lj(1f617%F�'t'f p r� a� R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Rooling Coverin
WS Window and Siding
ii SF Solid Fuel Burning Appliances
U dW "b( 1 Insulation
Tcie hooa Email addtxss D Demolition
5.2 Registered Home Improvement Contractor(HIC) i{/, ��,,1
Q�/�'u,,Wmmjyg'Q tr HIC Registration Number Esptrotion DaDdee
[MCC YK-Nameor1 � isl��nme llGd�(.s/N.t��Ll IClfr��Ykdli�' uti`
No -,((eey A^� -66-ba0( Email address
City/Town, State ZIP Y ' Tele hone
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 Islu ce of the building permit.
Signed Affidavit Attached? Yes ..........16 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,hereby authorize `Qetn I CecA+W tvftk h e-%W 1�ut ',LLB
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
(,oil-7'Ib
Print wn, Naive(Electronic Si ure) Dale
SECTION 7b:OWNEW 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,
B ar wl F b w,vl-_ (o (1-0 I o
Print Owncr or Aulhor]zed Agent's Name(Electronic Sigtmutre) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who]tires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will Trot have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
ivww mass eov'oci Information on the Construction Supervisor License can be found at www.mas�
2. When substantial work is planned,provide the information below:
Total Iloor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq.11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halflbatlis
Type of heating system Number of decks/porches
rype orcooling system Enclosed Open
3. "Ibtal Project Square Footage"may be substituted for"Totai Project Cost"
,F
07Yof SALFJK MASSWASE7T
itvZJ)MDBPAM26tvr
IqW IM WL9MWMS7tW,3oRoOJt
DL 7484M.
K FLnrnszg I XL PArPM74MO
MA]7Gdt 7tro�sST.PBnise
D c FPEMWjTavm/Bi w=amnz CFER
Construction Debris Disposa/Affidavit
(required for a►1 demolition and,.renovation workj
In accordance with the sbith edition of the State Building Code, 780 CMIv Section 111.5 Debris,
and the provisions of MGL Go,S 54; BuildbW Permit B Is issued with the
condition that the debris resu ft from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c ill,S lw&
The debris will be transported by.
vvlCf
(name of haulei)
The debris will be disposed of in:
MarblMed rf-4Ar�W 6-rAj-7ou
(name of facility)
(address of facility)
Signatur of pplicant
d
Date
'\ The Commonwealth of Massachusetts
Department of Industrial Accidents
a I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
ADDlicant Information Please Print Legibly
Business/Organization Name: 1rAAl-I yyn-Ld / rly gA try
Address: ZZ topIme ST)?4,CT— c�
City/State/Zip: M+� ,aSL�,fA-m [l 1p �IPh o e#: q/7 ` 746-
Are u an employer?Check three appropriate box: Business Type(required):
1. I am a employer with employees(full and/ 5. ❑Retail
orpart-time).* 6. F]RestaurantBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp, insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.�Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12. Other
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#I.
1 am an employer that is providin worketrs'compelnseation insurance for my employees. Below is the policy information.
Insurance Company Name:_
y _� 2 1• 9. �VJ U7,&t� , I W S 01?-4 UX.-
Insurer's Address: Q vet �41 e 0 +QVI-'vt�
City/State/Zip: tJ�LIluG�DI+�p M,4 , Dl go3
Policy#or Self-ins.Lic.# P&2—(Z 9 12-7 7 Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certify, u r the ainns and " naldes ofperju that the information provided above istrue and correct
Signature Date: l G/ 1-146
Phone 766 - 6e)61
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 your insurance company's name,address and phone number along with a certificate 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 permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). 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 dog license or permit to burn 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
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Forth Revised 02-23-15
Massachusetts -Department of ?utrJic Safety
Board of Buildigg Regulations and StilRdards
Comtructign Supcnixir I &2 Fafiih-
Licepse: CSFA-106187
BENJAMINPYBUtN `
22 PRINCE SIRgET -
Marblehead MA 6194 -JIB =
"- Commissioner - Expiration-`
1V23/2018 '.
i