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11 SUNSET RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY\ M� Massachusetts State Building Code, 780 CMR S Revisedd Mar 201! Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Only Building Permit Number Date A lied:,: Building Official(Print Name) _ - A Signature - Date. SECTION 1:'SITE'INFORMATION I.1 Pr--. ap�er_t�Addr�ss:o _ 1.2 Assessors Map&Parcel Numbers )A <.. .Y�� nca� I.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2:` PROPERTY OWNERSHIP" 2.j_—Qwnert or of Re d: locr � a ti vl�,l1 c leell M � o 1 � 70 me(Print) City,State,ZIP 1 ) 5(tm se f kda4 ?-7P- 7 S-49 b/s lae�h'g*g14 C2s?'.� No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) l New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': ` (A 0. \ory SECTION 4: ESTINIATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Nlaterials I. Building $ 'g 00© 00 1. Building Permit Fee:$ Indicate how fee is determined: y ` ❑Standard City/Town Application Fee . Electrical $ - - �ogrG ❑Total Project Costs(item 6)x.multiplier- x 3. Plumbing $ a000 ,0,0 ?. Other Fees: $ 4, Nlechanical (HVAC) S List:_, IE✓F6��� 5. Mechanical (Fire $ Suppression) Total All Fees:S tn� r ,�s'1 6o Check No. Check Amount: Cash Amount 6. 'rotai Project Cost: $ o�J�� ❑ Paid in Full ❑Outstanding Balance Due: r , t � SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) p ! 1 -7 *�,eI. L zasK� License NumberEspimtionDate Name of CSL holder LA List CSL"type(see below) i Sotti vva l C 7 No.and Street Type Description. J( Q (� Z q U Unrestricted2 Frn(Buildings u el ing cu. tl. I��'j' I R Restricted I&2 Fwnil Dwelling City/town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF I Solid Fuel Burning Appliances '261 631 ►S9 1 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(11C) , t /� �JBZ(o� 3 1S - L WA �.�V`S�'�4A. AY1 MJ..,I� H[C Registration Number rpvahon Date HIC Comp:my Name or HIC ROistm Name / 5,4L FMet'n 1n e No.and Street Email address t�s-ea &A0IgE 781 631 719 City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. g 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...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDrIN_G-PERMIT I, as Owner of the subject property,hereby authorize FLV / �,— Pe:e2C tt]act on my behalf,in all matters relative to work authorized by this building permit application. Print vner's Name(Electronic Signature) ate 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. ��rel L Oo s cuss t�✓l�� � !l S 1 ��3 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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 not have access to the arbitration program or guaranty fund under NLG.L.c. 142A. Other important information on the HIC Program can be found at www.mass.,>ov'oca Information on the Construction Supervisor License can be found at wwwjuass.^ov`dns 2. When substantial work is planned,provide the information below: 'total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. ft.) 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 3. "Total Project Square Footage"may be substituted for"Total Project Cost' �! CITY OF S:1L. m, lt'LASSACHUSETTS BL'ILOLNG DEPARTM&NT 3 s} ) 120 WASHLNGTON STREET, 3'o FLOOR '� � TEL (978)745-9595. F.tx(978) 740.9846 • KIJ(BERt FY DRISCOLL MAYOR THoJIAS ST.FMM DIRECTOR OF PUBLIC PROPERTY/BCB.DLNG CO%L%BSSIONF& Workers' Compensation insurance Affidavit: Builders/Contractors/Electrfelans/Plumbers Applicant information 4� \ `Pl-ease- pPrint Legibiy / NairC(Business,OrganizatiorvIndividual): L \.rC�+'-Gh.Q Q�-7 Let 011t LL C, Address: 1 �O w ►^ kP�u City/State/zip: �-S fey N A-O IRZ2 Phone#: __7 8 1 10 `T Are you an employer?Check the appropriate box- Type of project(required): I.OTI am a employer with 5— a• ❑ 1 am a general contractor and 1 6. ❑New constn ction employees(full and/or Part-time).* have hired the sub-contractor 2.El am a sole proprietor or partner- listed on the attached.sheet t �• ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working.for me in any capacity. workers'comp.insurance. 9, ❑Building addition [No workers'comp.insurance 5.0 We are a corporation and its. required.) officers Have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or odditions myself.(No workcrs'cump, e. 152, 1(4)and we hive no 12.❑ Roof repairs insurance required.)t employees:[No wormers'; lJ.❑Other cump,insurance requircd.j, 'Any applicant that chucks brae al I must a1:W fill Out the sccden below showing they workeis'ampMwiao polity infurmatfom '1 i.vneuwrans who submit this affidavit indicating they ors doing all work and then hire outside caNrouors most submit a new aftwavit indicating such :C.mumctoo that chc<k this box meet anachod an mWittunal sheet showing the name of the subeontnctons and their workers'comp.policy intorrrunon. fain an employer tbaNs pravldiag workers'compensation iresurancejor my employees Below is the policy and Job sirs st injorrnmiam Insurance Company dame-.. 6K0_.r- AV</S K.raVi l,',Q_� C 6 Policy U ur Sclf-ins.Lie. 0: F LW G q pZ(Pyz_ Expiration Data:— / -7-- 3 _�'t Q Job Site Address: t I S tt ✓t SeJ' fLd City/Statr/zip: 5�EL_fII/1 ! r vJ-1 70 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 tine up to SI.S00.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to SM.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the office of investigmimtsul'the DIA for insurance covcrogavariticatiun. file hereby certify under the pubnr unql penald•s ajperiury that the brjurmuaton provided above is true and correct. SI n ruse' Duro 1'hona,i: $ / 6 / 7 1 1-1 Ojfrciul use only. Do trot write in this arery to be completed by city at,town ojflcial I City or Town: _ Ycrmit/i.lccnse p Issuing Authorily(circle one): 1. Bourd of health 2. Building Department 3.Cityffown Clerk J. Electrical inspector 5. Plumbing inspector 6.Other _ Conlaci Person: Phone B: [ `° CITY OF S.kLEEm, i�rlASSACHUSETTS BuiLDNG DEPART�t&NT A 120 WASHLNGTON STREET, 310D FLOOR k a� TEI- (978) 745-9595 FAx(978) 740-9846 IC %g3ERi EY DRISCOLL ib1.�YOR T'HoatAs ST.PIERRe DIRECTOR OF PUBLIC PROPERTY/BCII.DNG CONLUISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) Tn accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111,-S 150A. The debris will be transported by: ,y F1—QP9z(J �o �5��-TCO V1 (name of hauler) The debris will be disposed ' of in (name of facility) 1�Sham 5 a* S� t It'l - (addr ss of facility) i signature of permit applicant date Jcbtisa iT d.x Massachusetts- Department(ofPublic Safct% Board of Building Re�mlations and Standards Construction Supervisor License License: CS 66176 ra. . - FRED L DESCHENES 1 SOUTHERN HEIGHTS ESSEX, MA 01929 - c�-.L iy fll� Expiration: 9127/2D13 ('onnnissiu„rr Tr#: 3543 Vlee y�m�eo�emnr�eaQ/c��'�/ r,'.'ru'�'G" s License or registration valid for individul use only Otree of Consumer Affairs&Business Regulafioa before the expiration date. If found return to: We ME IMPROVEMENT CONTRACTOR - p{{ce bf Consumer Affairs and Business Regulation istration. 138262 Type. 10 Park Plana-Consumer Af 170 p�ration .3/13t2015. Ltd Liability Corp Boston,MA 02116 F L DESCHENES CONSTRUCTION:LLC. _ FRED DESCHENES 1 SOUTHERN HIGHT§. ESSEX,MA 01929 Undersecretary Not valid vAbout signature i