0013 - 0015 SALTONSTALL PARKWAY- BPA-16-1035 e-71 7 C� Cr— 521 7 �
{�gtf RI�.��r���t
The Commonwealth of MassacllCisei CITY OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 7191VO Ij O A 10. 3 Revised lE r1201I
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
n This Section For Official Use Only
(V�O Building Permit Number: I Date Applied:
iDuildingOtticial(Print Name) ,Signature - - Date
y SECTION 1:SITE INFORMATIO W
1.1 Prop e Address / rep r 1.2 Assesso blap 3r Parcel Number
1V 1 I.la Is this an accepted street?yes_ .no . b umber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(II)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6\Pater ly:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al❑ On site disposal s stem ❑
Public Private❑ Check if es❑ P y
SECTION2: PROPERTY OWNERSHIP'^
2.1 O t of ecort�, v
'�"os 1Jr)�rf
Rime(Print) City,State,ZIP
t 3 - S S�J+Alj S fit 10))14
Nu.and Street elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK!(check all that apply)
New Construction❑ Existing Building Cl Owner-Occupied ❑ Repairs(s) ❑ Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
t° C. e C9 P
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
Labor and Materials)
I. Building S a 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S o ❑Total Project Cost'(Item 6)x multiplier s
3. Plumbing S 2. Other Fees: S
4.Mcch.,mical (11VAC) S List:
5. Mechmtical (Fire S Total All Fees:S
Su ressiun)
Check No._Check Amount: Cash Amount:_
6.Tot:d Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
C%t��.� Fo2 P � •
F
SECTION 5: CONSTRUCTION SERVICES
5.l Cons ructimr Supervisor License(CSL) CS
tea/ �-
�C — 4 .P.�. L{iao'se-7Nto bber E tratio Date
l
Name of 'SL Holder List CSL'rype(see below)
-36 /t1i[rr i Type Description
No.;aid Street
S C U Unrestricte
2' Itd(BuildingsLID-to 35,000 ca. It.)
Restricted 1&2 Family Dwelling
'ity/rown,Sta "LIP M masonry
RC Rooting Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 Insulation
Tcic hung - Emm address D Demolition
5.2 iste ed e/Home Improvem of Con ractor(HIC) /
&,I.1a [IfeWgistfulion Number Expiration
fIICC y am orfll(JyRegistr tName
No.an Street Email address
City/Town' State P Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.¢25C(6)J.
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isluanc a building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED.WHEN:
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERr OR AUTHORIZED AGENT DECLARATION
By entering my name below,) hereby attest under the pains and [ties ry that all of the information
contained in this.application ist and acc✓te to the bes my kn le a and nderstanding.
Qa 4 r 999
Print Owner's or Authorized Agcnt's Name(Elwtronic Sigamua at
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 LLyl have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program can be found at
wwvv macs eov'oca Information on the Construction Supervisor License can be found at wway.naass.�,ov'dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. 11.) 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
1. "total Project Square Footage"may be substituted fur"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 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.
Applicant Information Please Print Legibly
Business/Organization Name: ci la -
Address: , r
City/State/Zip:. , e/ d Phone#i' "
Are yo employer?Check th appropriate box: Business Type(required):
1. I am a employer with employees(full and/ 5. ❑Retail
or part-time). 6. ❑Restaurant/Bar/Eating Establishment
2.❑ 1 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.❑Manufacturing
no employees. [No workers' comp.insurance required]* 11.0 Health Care
4.❑ ,We are a nonit 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.
I ant an employer that is prov' tag orker 'compJ�+esadon insurance for my employees. Below is the policy information.
Insurance Company Name: Ir'�iS Q7✓•'ems C
Insurer's Address:
City/State/Zip: p ) ^n
Policy#or Self-ins.Lie.#WY 0V J Pry V I,��r � ^(T011'ql Expiration Date: V Nr4F
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ex iration 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 faLrisurance covera ' Ication.
I do hereby cer ' ,under the p 7ts and nalties of p jury that the information prov' ed abo is true and correct.
Si nature:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
1
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 Persoru Phone#:
www.mass.gov/dia
1
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
Fenn Revised 02-23-15
LrIYOFSALEA MAsmi sun
BtnAMDtBPARnMNr
$�EitiBYD waxL PAr MP-M 6
MAYM 1�iowssS7.P
Dnxcrm cFPUUxjF IOw/BiII1TM aAM
Construction Debris Disposa/Affidavit
(required forall demolition and.renovation workj
In aorordance with the sbA edition of the State Bush ng Code, 780CMR, Sectbn 111.5 Debd4
and the provisions of MGL coo,S 54; Building Permit# , Is issued with the
condMon that the debris resukbg from this work shei be dhpused of in a property Rcensed
waste depastt facility as defined by MGL c ill,S 156A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of fadlity)
(address of facility)
i re f applicant
Date
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massach,14setts 02116
Home Improvement Co, tr�ctor Registration
_
Registration: 113541
Type: DBA
z Expiration: 6/28/2017 Tr# 267566
DOUBLE D CONSTRUCTION ("
DOUGLAS DUBIN
36 ORCHARD RD. w
SWAMPSCOTT, MA 01907 A
e'" Update Address and return card.Mark reason for change..
scA1 0 20M-05111. Address ❑ Renewal D Employment Lost Card
�ia�omvnaom2uca�o�P/�.crnacecLueaelZi
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
UlfOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration .`]�13541 Type: Office of Consumer Affairs and Business Regulation
xpiration 6/28/2017 DBA 10 Park Plaza-Suite 5170
iE
Boston,MA 02116
DOUBLE D CONSTI2UCT10N,�1
DOUGLAS DUBIN
36 ORCHARD
SWAMPSCOTT, MA 01907' --
Undersecretary Not valid without Signature
Massachusetts Department of Public.Safety
®r Board of Building Regulations and Standards
License: CSFA-059622 t
Construction Supervisor 1 & 2 .m
Family , ..t ,. •e"{- ,
DOUGLASG DUBIN
36ORCHARD ROAD'
�s -
SWAMPSCOTTMA 07907�
Expiration:
Commissioner 02/17/2018
NOTICE a NOTICE
TO TO
A
EMPLOYEES .� b ,� EMPLOYEES
ey aAJ
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you
notice that I (we)have provided payment to our injured employees under the above mentioned
chapter by insuring with:
Associated Employers Insurance Company
NAME OF INSURANCE COMPANY
P.O. Box 4070 Burlington, MA 01803-0970
ADDRESS OF INSURANCE COMPANY
WCC-500-5013528-2016A 06/15/2016-06/15/2017
POLICY NUMBER EFFECTIVE DATES
15 Pacella Pk Dr Ste 240
Risk Strategies Company Randolph, MA 02368
NAME OF INSURANCE AGENT ADDRESS PHONE
Double D Construction LLC 21 Elm Place Swampscott, MA 01907
EMPLOYER ADDRESS
04/29/2016
DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL FACILITY
HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER