43 SUMMIT AVE - BUILDING INSPECTION The Commonwealth ofhlassacfiusettsI�PEC71QTSEVjCg4.TYF
Board of Building Regulations and StandardsMlassachusetts State Buildin Code, 780 C0ti g ApRt lBuilding Permit Application To Construct, Repair, Renovate Or i7e
One-or Tivo-Family Dwelling
`} This Section For Offidal Use Onl
Building Permit Number: Date ppliedt
Building OtTiciul(Pont Name). Signature '.- Date
SECTION 1:SITE INFORMATION.'
I.1 Pro erty AddreM 1.2 Assessors Map&Parcel Numbers
!f� m 7 AV
L 1 a is this an accepted street9 yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District, Proposed Use Lot Area(sq it) Frontage(R) -
z: 1.5 Building Setbacks(R)
.. F_Front Yard _. . Side Yards Rear Yard.
Requiic Provided Required Provided. Required` ' Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O_ .On site disposal system 0 -.
Public O Private O. Check if es�-
SECTION2: PROPERTYOWNERSHIP!'
2.1 Owner'of Record:
A1V71�OLy CCAma�Rf1S
tTfine(Print) City,State,ZIP
S4m 791-3 9/8s
No.and Slrect Telephone Entail Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all thatapply)
New Construction O Existing Building Owner-Occupied Repairs(s) O 1 Alteration(s) 0 1 Addition O
Demolition O Accessory Bldg.O Number ofUnits-�--/ Other OI(Speciiy:11YA7X6kZATIQA/
Brief Description of Proposed.Work=:
1A1fr//�ja n i r "' 1' EXT �16. Ok 11RLLS //SinIP r1LfJldd) CELL ULO Ste'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offle)al Use Only
Labor and%laterials
I Building od I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Tosvn Application Fee
2. Electrical S ❑Total Project Cost'(item 6)s multiplier s.. -
3. Plmnbing S 2P Pther Fees: S
4. Mcchanical (FIVAC) S List: r x
5. Mechanical (Fire S Total All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:
G.'rotal Project Cost: .S 2 08,ea Cl Paid in Full ❑Outstanding Balance Due:
c.. :! SECTION5: CONSFRUCPIONSERVICES
5.1 ConstructionSupe-ry Isar License(CSL)
QRAh �9A/O,F F,�. �'r' �,�•� zl;t License Number Expiration Dale
N;une of CSL Huldei '
List CSLType(see below) (J
MMAI Ah Tye - : - Description
No.and Street - e-
U Unrestricted(Buildings tip-l0 35,000 cu. tl.
//RKE Lb /fy9 0��8� R Restricted 1&2F:unil Dwelling
City/1'u�m,Stole,ZI M Masonry
RC Roolin Covcrin
WS Window and Siding
SF Solid Fuel Burning Appliances
6/7- sw`6cH 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) / 0 SOS
ST/CCR CO/V7 AC 7iA/r C0 111C Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
?L "3'11Ie/G y,rN S T
r1hi
andet - Email address
EAr IPA Oa/-1/,P 6!7 S9z-�875
State ZIP Telephone
TION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M lG.L.c.15Z.§25C(6))
ompensation Insurance affidavit must be completed and submitted with this application. Failure to provide
it will result in the denial of the Issuance of the building permit
idavit Attached? Yes .......... 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 ST/CCf� COV7RAAlls CD
t9 act on my behalf,in all matters relative to wor authorized by this building permit application.
hx"oXJ y - 1 /r-,�27-/G
Print Owner's Name(Electronic Signature) - Date
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 understan/d/ing.
te
Print Owncr's ur Authorized Agent's}Janie(Electronic Signature) Date
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 Imrovement Contractor(HIC)Program),will LWI have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information onthe HIC-Program can be founds ar
www mass eov:'oca Information on the Construction Supervisor License can be round at twvw.ntas�
2. When substantial work is planned,provide the information below:
'total fluor area(sq. R.) N .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room coma
Number of fireplaces Number of bedrooms
Nwnber of bathrooms Number of half/baths
'type of heating system Number of decks/porches
'rype of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted fur"Read Project Cost"
The Commonwealth ofMassachuseft
Department oflndusfridAccfdents
Office ffinvestigaffous .
600 Washington Street
Boston,MA 01111
wwrtvnass govMa 1
FVorlurs'Compensation Insurance Affidavit:Bullders/Contractors/Electicilm Plumbers
npLe� t Istarmation - _Please Print Legibly
Ntlttre Srfi �d P��� ik' !�.
Addreas: 174 &MSAkA&nw m
CityAhatemp: Phone#: ,(d7 JI - Add
Are Xon an aapl*W Cbedc the appropriate box: Type of project(regnbvd):
1.Gri am a employer with_A 4. [3 I am a garaal cantamor and I 6. [3 New constutdon
earployeea(foil and/or pertrtimc}* huge hired the sub-contractors
2.01 am a sole proprietor or partner- listed on the attached shut.t 7. ltar»deling
ship and have no employees .These sub-contraetars have IL n Demolition
vAnk og forme in any capacity. workers'comp.kuxasam 9. O Building addition
[No work= ram•insurance _ S. 0 We are a empmation and its 10.0 Electrical repairs or adder
reqamcers have acerdsd that
3.01anaahhomeownerdoingallwork rightofemnpdmrparMOL il•[:)nmd agrepairsoradditions
rnywpf Wo workers'comp a 152,$1(4) and we have no ll[)Roof reps
insurance required.)t employem[No workne 13.[]Other
comp.insurance requin4]
•AarappticantkarA—%-b=#1w=&t=jMad6a=c*wbd* AvwWXfiteirwoe=V=nv=Nf=Paftktor
LFBaaeewan wLca a�&affidaraiaaba*afgaoadoig mwwt and&m Loa vowdo ®mmwmaalsokamw a is' Itkdmftuel.
tCowaaoadatdeot ditbmc amtabchadae WeAmar*,mAew®a the awe ofanesdwoeasom ad bobwwker enma.VARY bdbmeaen
1 arc an omprvJp that tt providbrg wvrkwe.g ompensaeion insane for nyvmployetr. Below it ae poliq and job du -
informadva. .
Insurance OompanyName: 7f>:tPL A�A I .dam .Poucyvor&m&Lic.#: �B-a '�'4�Js9g EpirsUdnDarknY tAL
)obSiteAddrma j/3 SU/r1mi� AWf (StylSmtrll�: _SALE--t?A C.LJ70
Attach a copy of the Workers'compensation policy declaration page(showing the polky number and expiratlen date *
• Failure to secure coverage u required under Sean 25A of MOL c. I52 on lead to the imposition of crimbW penalties of a
fmo up a 51,S000W mdkr ono? rimprinamma,as well as civil pemddesin the Emm of a STOP WORK ORDifft and of n
of lO m S2SILD0 aday agamstthe viohdor. Be advised that it c*of dds sta craantmaybe fofwarded to the Office of
In oat of the DIA for imu ance cwvaage vaification.
r de busby awdry aader the abet andpanaEtiar eypeyary tbattlre brforsratianprovidad abox tr true and cornet
signsturn
Pimrretk /?-53►1•(,�i(9
t 01ci t an V4. Do nor write in thlr anm to be eomptesrf by dry grow agmtat
City or Town Permit/Lieeose S
lasuire Authorhy(circle one):
F.Board of Bealth 2.Building Depirtaaent 3.City/Town Clerk 4.Electrical Inspector 5.PlumbioYInspect or
r=ar
Contact Person: Phone M. . ..
Cnmtracuen Snpernimr
- ==-se CS-logsB
BMDL"DANOFF
15 MARWN ROAD _
wakeffA t MA 000
unrestricted-Bmld1 ias of any use group which
claim hen 35,000 talbic feet(991m)of
enclosed apace. _
Fasure to a cvramr edltlon of the Ma$achusetts
ate&raft Code is crose for reuocohm of this license.
FWMUCMAV dormMVDnvivt wwrrMass.GM/M
Office of Consumer Affairs and Business Regulation
Vi 10 Park Plaza - Suite 5170�
Boston, Massachusetts.02116
Home Improvement Contractor Registration
Registration: 110505
Type: Supplement Card
Expiration: 10/202016
STICCA CONTRACTING CO
BRADLEY DANOFF
376 WASHINGTON ST
MALDEN, MA 02148 _. _.. . . _ _—.-- . ,_.. .
Update Address and return card.Mark reason for change.
i"I Address I ReaewJ ;,f Employment 1"'I t.ost Card
'�,A7 8 rlstoAri7 tt .
9(ir f!t"N , "^Wfr✓i
Office of Consumer Albin&Business Regulation License or registration valid for individul an only
j before the expiration data If found return to:
it riWME IMPROVEMENT CONTRACTOR�`.1�1 Office of Consumer Affairs and Business Regulation
; ,5'Yv Registration: 11=5 TYPO. 10 Pnric Plaza-.suite 5170
Expiration: 100=16 Supplement Cad Boston,MA 02116
STICCA CONTRACTING CO
BRADLEY DANOFF
376 WASHINGTON ST �- " /1__
MALDEN,MA 02146 Undersecretary - — - Not V without signature