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1 SYMONDS ST - BUILDING INSPECTION
C4<1 131 Z cb 2ob f3- lU -/ 9z� The Commonwealth of Massachusetts $ Board of Building Regulations and Standards INSPECTIONQ SE�V ' �F°. Massachusetts State Building Code, 780 CMR � SALEM l RAisHA AW 011 Building Permit Application To Construct, Repair,Renovate Or IJh4P1oYrS�i a' One-or Two-Family Dwelling 0 v This Section For Official Use Only Building Permit Number: Date pplied: q Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 lSop.:.Address: 1.2 Assessors Map& Parcel Numbers � o..rc1S SJ f� 1.1 a Is this an accepted street?yes—V no Map Number Parcel Number 11�IL,. 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 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: Zone: _ Outside Flood Zone? Public Private ElCheck ifyes❑ Municipal V_On site disposal system El SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: �1 �£M e_ W b 5" z2-"L- _r,ff, .t l .t 0 l �p 7 0 Name(Print) City,State,ZIP 1 S31K0Ilds Sr ?5/_ 03t6 --4f175_2 PRD CO. -S , E No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ 1 Existing Building❑ 1 Owner-Occupied ❑ xationis)k6 I Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work': Al c", it) ew SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 2-0 000 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ` O ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 10 0 o 0 2. Other Fees: $ /� 4.Mechanical (HVAC) $ S 0O O List: �rk.� 5.Mechanical (Fire $ Total All Fees:$ Su ression Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 40 000 ❑ Paid in Full ❑ Outstanding Balance Due: 5t,NT SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C � "� s v92 9 4 I'E-c2_ C IA Lr-vzz [—S L— License Number Expiration Date Name of CSL Holder L) List CSL Type(see below) Le Zl{ 9 L-(-r lC i? Type Description No.and Street , 1I3la � �. ,t I U Unrestricted(Buildings u to 35,000 cu.ft.) M /� t 4� R Restricted 1&2 FamilyDwelling City/Town,State,ZIP M Masonry CQ u ,?q,1- 3 )1- ' 4 7 S•-Z RC Roofing Covering WS Window and Siding (.7 I SF Solid Fuel Burning Appliances ((/ t931Z I A4'r4,,ABS. A eo,,,,�.p-�i,.r 1 Insulation Tele hone Email address D Demolition L 5.2 Registered Home Improvement Contractor(HIC) ` qq b `� Z ( ) 3o ( Ib VB -1.,e PbH �N 2249 HIC Registration Number Expiration Dale HIC Company Name or HIC Registrant Name Z-14LL o S 1--:11 2� �£T4T 0iF $� Cv. PJlST. ✓ f No.and Street Email address >ti1�+3lyl« d J,) A © (g4 '7g )- 31 6-4-i5z Ci /Town, State,ZIP Telephone 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 Issuance of the building permit. Signed Affidavit Attached? Yes ..........91 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 7 cJt— P. brtYt ? e,- 3 � to my behalf,in all matters relative to work authorized by this building permit application. /AIT'•1/�n`-� �t rVz, l-(U�/+-�z2.£S� Z ( �a 11/ 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 crV7in thisa plication is true and accurate to the best of my knowledge and understanding. � p,-, W� �rv-LZ4_SE LZ 10 1 Print Owner's or Authorized Agent's Name(Electronic Signature) ate 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at wnvw.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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" Massachusetts -Department of Public Safety ee of Consumer Affairs Regulation Boand of Building Regulations and Standar ds •'+:. ME�IMPROVEMENS CONTRACTOR ,. Bistration 146662 Type: - - License: 6&092794 xpiraton 1/3012016 Individual s PETER C ABBRULE � PETER ABBRUZZIE .r - 24 LEGGS WILL" ae — + r M;ARBLEHEAD 1GIA U . PETER ABBRUZZESE�' t �, _ - 24 LEGGSHILL ROAD 4" 't " '+' Expiration MARBLEHEAD,MA 01945 Undersecretary 02/03/20Y5 Commissioner I I j� I CITY OF &UMA, imASSAcHus=s • &:II.DLNIG DEPARTNIENT ' 120 WASHINGTON STREET,3"FLOOR T Et_ (978)745-9595 FAX(978)740-9846 KIMBERLEY DRISCOLL IMIAYOR T NOMAS ST.PIERRE DIRECTOR OF PuRLIC PROPERTY/aL'ILDMG CONMSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibiv twss Name(ausi ,,organization Individual): hon 4?c_,� le4 6 Address: 6l e-�-6L9t T City/State/Zip: `ice Phone N: 3 3 `l' r �f�C�� LF 7z1z7 Are.you an employer?Check the appropriate box: Type of project(required): 1.gi!�1 am a employer with�— 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-tune).' have hired the sub-contractors �,{� 2.El am a sole proprietor or partner- listed an the attached sheet.t 7. „t�1 Remodeling ship and have no employees These sub-contractors have :J. El Demolition working for me in any capacity, workers'comp.insurance. 9, C1 Building [No workers'comp. insurance 5. El We are a corporation and its addition required.] officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant that chucks twat NI must also fill Out$he section below stowing their wast m'wmpenmion policy mrormmion 'I inmemvtwrs who submit this aatdavit indicating'hey ate doing all work and then hire outside commcton most submit a new,a?tdovil indicting such :Conttxcton that check this box must anxhod an additiomd'hect-h-wins the name*(the sub.eontractwa"a their worse'comp.policy inrwmation. 1 um in employer that Is providing workers'compensation insaroncefor my employers. Below Is the policy and jab site information, q l �C/�/•� /� Insurance Company Name:_ /V oe- Af2Gt' S Vf-A-✓r f Ce,-,t�,d-AJ we z&�7� �J � _ Policy H or Self-ins.Lie.b: — Expiration Data:_✓ // /,T ' Job SireAddress: I ) tlAW' S J? City/State2ip- .f4✓{o,✓I 114 19 /9 71 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration hate). 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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statemcrot may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby carry t the ins and penaIII ojperjury that the information provided above is true and comet Si>_namre: Date l�7 / /01 Phoney: 3 / �U Z • C / Ojjkial use only. Do not write in this area,to be completed by city or town ofcialt City or Town: Perm(tR.icense Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other , Contact Person Phone p: J x NOTICE NOTICE TO ' y TO EMPLOYEES K EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 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 for payment to our injured employees under the above mentioned chapter by insuring with: NorGUARD Insurance Company NAME OF INSURANCE COMPANY P.O. Box A-H 16 South River Street Wilkes-Barre, PA: 18703-0020 ADDRESS OF INSURANCE COMPANY FAWC426176 03/11/2013 03/11/2014 POLICY NUMBER EFFECTIVE DATES PAYCHEX INSURANCE AGENCY 150 Sawgrass Drive 877-266-6850 Rochester NV 14670 - NAME OF INSURANCE AGENT ADDRESS PHONE Fast Track Realty LLC 82 Alley St Lynn MA 01902 EMPLOYER ADDRESS 03/15/2013 EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) 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 ser- vices 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 DIAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER i CITY OF S.UENI, N'IASSACHUSETTS • BUILDING DEPART TIENT 130 WASHINGTON STREET, 3' FLOOR TEI.. (978) 745-9595 FAX(978) 740-9846 K(afBFur RY DRISCOLL MAYOR T HomAs ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUa DING CONMSSIONER Construction Debris Disposal Affidavit (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 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: r S�cS A— f (name of hauler) The debris /will be disposed am off in : 14 (I�f'� f/yAs7� (name of facility) (address of facility) signature of permit applicant CZ to (� data debdwIldm