11 SUNSET RD - BUILDING INSPECTION (3) I(pl r� -*let's
,a
.RECEIVED
The Commonwealth of Massachusetts CITY OF
y,� Board of ewse N building Regulations and Standard
4� Massachusetts State Building Code, 780 CM016 NAR -3 Ie�EM
ar 1211
Building Permit Application To Construct, Repair, Renovate Or Demolish a
D_ One-or Tivo-Family Dwelling
This Section For Official Use Only
I
DuiWingecrniitNumber., D teApplied:
DuilJing 017Out(Print Name). Signature - Date
SECTION 1:SITE INFOR+NIATION`
t I Property Addresr 1.2 Assessors MAP&Parcel Numbers
X` I sICr]Ge�
I.It Is this an accepted street?yes_✓ 'no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District - Pn+poseJ Use Lot Area is
R) Fronmge(R) - -
1.5 Building Setbacks(R)
Front Yard - ' Side Yards - Rear Yard
Required Provided Required - Provided- Required- ` Provided
1.6 Water Supply:(M.G.L e.40,§54) !1. Flood Zone Information: 1.8 Sewagee Disposal Systemf� Private❑. e: _ Outside Flood Zone? Municipal Pl On site disposal system ❑
Public - Check if es❑
SECTIO 2: PROPERTYOWNERSRIP!
2.1 wnerr of Record:
i 7f �
aYd 1'Soo.� kaA'ha�
N7 Sm /�n� /Yl�
me(Print) City,State,ZIP
1/ ! ran5et Am,,e 97 st<N�f
No.and StreetTelephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) l] Altemtion(s) O AJdition ❑
Demolition O Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
brief Description of Proposed Work': a '�l r'v-1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Itc-t� - MOOO
osts: Official Use Only
aterials
1. Building •00 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical •0 0 ❑Total Project Cose(Item 6)x multiplier x
3. Plumbing p 0 22N Qther Fees: S4. Mechanical (tIVAList:5. Mechanical (Fire "total r\II Fees:5
Su ression) Check No. Check Amount: Cash Amount:
6.Tutal Project Co0'. ❑Paid in Full ❑Outstanding
balance Due:
OnAt L To suosv ,v r p
ILt At Leo 3( u
SECTION 5: CONSTRUCTION SERVICES
5.1 Cmtsfftruction Supervisor gLicense(CSL) 0 (0(o 1-1 G 9 L7 17
ik 1 •' fit 4 {1llm n'
� 'I License Number Erp radon ate
Name of CSL Holder List CSL'Type(see below)
I So l�k1�a.r Inn �n�5
Type Description .
Nu. and Street
p (�N� Unrestricted 1 2 F;uni tip-to elling 00cu. ft.)
/ R Restricted 1&2 F:unil Dwelling
C ityll"mm,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding:
SF - Solid Fuel Burning Appliances
7$t•631-7f B 1 Insulation
\ , Telephone Email address D Demolition
X ' 5.2 Registered Home Improvement Contractor(HIC) 'j
�,FJO'LBTr uzk 01/� U".. HIC Registration Number Expiration Date
i IIC Corn any Name or HIC Reg�stranl Name
7 Ll1.1/�f".r-rn ia/i �
No nd Street $ ;/ ?C Email address
s a� MA- 01927
citvrrown.State ZIP Tcle hone
SECTION 6:WORKERS,COMPENSATION INSURANCE AFFIDAVIT(M.G.1: c-M.§25COW
Workers Compensation insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isivance of the building permit.
Signed Affidavit Attached? Yes .......... No...........Cl
SECTION 7a:OWNER AUTHORIZATION TOBE.COMPLETED.WHErc "
OWNER'S AGENT OR CONTRACTOR APPLIES:FOR BUILDING PERMIT
111,�
" I,as Owner of the subject property,hereby authorize I'{ 1> GG7
t9 act on my behalf,in all matters relative to work authorized by this building permit application. ,
o n ;�tZ it ha.�- �' �drL��c� Jam• 7 O/(e
Print Owner's Name(Electronic Si ure) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,)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.
�`�i�at/ L �c�w.uar�� • �� 3 f 16 .. .
IY it Owner's or Authorized Agent's Name(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 Improvement Contractor(HIC) Program);will LLof have access to the arbitration
program or guaranty fund under M.G.L.c. 1I42A.Other important informad onthe-MC-rogram can be�ican t
www mass.eov:'oca information on the Construction Supervisor License can be found at www.nas�
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) (including garage, fiinished 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 tur'"fotal Project Cost"
a
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston, MA 0211 4-2 01 7
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNHTMG AUTHORITY.
Applicant Information Please Print LeL41illy
Name (Business/Organization/Individual): L �.B�j ^A�_9� m ..�'� n Re,
Address: In
City/State/Zip: iFX P`pt O o z_7 Phone#: —7 l $$
r4.
you an employer?Check the appropriate box:
Type of project(required):
a employer with Z employees(full and/orpart-time).' 7. ❑New construction
Iam a sole proprietoror paronership and have no employees working forme in 8. emodelinany capacity.[No workers"comp.insurance required.] �-` gI am a homeowner doin all work m elf. 9. ❑Demolition B ys [No workers'comp.insurance required t I am a homeowner and will be hiving contractors to conduct all work on m property. 10❑Building addition
Y P pent'. I will
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a genera]contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.* 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their tight of exemption per MGL C. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such.
tContracmrs that check this box must attached an additional ahem showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide then workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: r t lta_V-d �/�-5 V-�Cl yl(�,� G O
Policy#or Self-ins.Lic.#:_ F LEA)C, �03 g 6 S 11 Expiration Date: y ]'Z3 ('6
,y --IT
Job Site Address:_I/ soh 5 G/ KOQd �� V City/State/Zip: �( 0192q/'
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under"the pains and penalties of erjury that the information provided above is true and correct.
Signature T/T �/�� YZ���+ Date -3
Phone#: -7 ir/ 6141 71 67 0
F
al use only. Do not write in this area,to be completed by city or town officialr Town: Permit/License#
g Authority(circle one):
rd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
ert Person: Phone#•
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,constmctiori 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` ubdivisions 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 sub-contractor(s)name(s),address(es)and phone number(s)along with their cenificate(s)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,io 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)and under"Job Site Address"the applicant should write"all locations in - (city or
town)."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, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
07'Y OF SALEA A ASSAa"ETPS
BuimnYGDEPAmAr.xr
120 WAgWYC ONSUM,3IDFLOOt
hL(978)745-9595.
RtMRFRi-F
YDRISODLL PAX(978)740-9846
MAYOR 7)iCMAS STYMM
DntEcTcacFpumucpRoFmy/Buue4Gcom&=DTn
Construction Debris Disposa/Afdavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit 4 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
FVt'4 Vel
(name of hauler)
The debris will be disposed of in:
(name of facility)
o",Ae,-Vo wA-) V4 A
(address of facility)
Signature of applicant
3 / 3 � 15
—T— Date
U
tTice of Consumer Affairs&Business Regulation
OMEatiom IMPROVEMENT CONTRACTOR
egistration , 138262 Type:
xpiration: 3/13/201r7 Corporation
F L DESCHENES CONSTRUCTION'INC
FRED DESCHENES ,,' _
1 SOUTHERN HIGHTS
ESSEX, MA 01929 Undersecretary ..
> Massachusetts Department of Public Safety
�J Board of Building Regulations and Standards
License: CS-066176
Construction Supervisor
-FRED L DESCHENES
1 SOUTHERN HEIGHTS
ESSEX MA 01929 ; g
+.e
1r�'Jzu Expiration:
Commissioner 0912712017