20 THORNDIKE ST - BUILDING INSPECTION (2) •+� Z
� v
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
(, Massachusetts State Building Code 780 CNIR SdMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish
One-or Two-Family Divelling
This Section For Official Use Only `
Building Per Number:-. Date Applied
{ + p
7�Z�7Apc,.+�
Building Official(Print Nan e) Signature Date
SECTION 1: SITE INFORNIATI
Ll Property Address: 1.2 Assessors Map& Parcel Numbers
1.la 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 ft) Frontage(ft)
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 yesO
SECTION 2:'PROPERTY, OWNERSHIP�' r'
2.1 wnert of Re rd:
/�!t [{rr o cll��/L S. Gcrwl
Name(Print) City,State,ZIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied CI I Repairs(s) .4lteration(3) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ I Number of Units_ Other,❑ Specify:
of Description of Pro osed Work': J< ln44eyjG
cr --e eV aVI G--A,C c�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: 11
Item Official Use Only-
Labor and N[atcrials
1. Building s 1. Building Permit Fee S Indicate how fee is determined:
2. Electrical
❑ Standard City/Town Application Fee.
S
❑"fotal.Project Costi. (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
1. Mechanical (HVAQ S List:
i. Mechanical (Fire 5
Su ressiuit) _ Total All Fees: :S
Check No. Chcck Amount: Cash Amount
l'otal Project I'ust $ ty v�, ❑ Paul in Full Cl Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction
�Supervisor License(CSL) G J� (0Z) 4L)
�I t/-/,4 `�/ XZr'd-Gz u r�G LicenseR..n eer C. piratiote
Name of CSL I I Idzr
/ �` List CSL Type(sae below)
,Y—`
/`m 4 (,C— �/�Cr/'C/-- Ty e - Description
No Street S`,
t ff n if�� ��` f`/ U Unrestricted 2 Family
s u el ing cu. I2.
/L �(/� R Rzstrictcd 13t2 Tamil Dwelling
City/Town, State, ZIP bI Ndasonr
RC Rooting Covering
WS Window and Siding
Solid Fuel Bunting Appliances
Insulation
relz hone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) doC G/Q (t.CD LD f el- O0r aw y FI[C RegistratioonNumber E.p�tion Date
IIIC Compan Name or I-[IC Rcgist nt Nm f,�,,/
S i��t��LL C trX UeDL 0 6, / l oCOG�
No. Email address
City/Town,State, ZIP tJ 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 .......... No ...........❑
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
to act on my behalf, in all matters relative to work authorized by this building permit application.
M, lair I'7ff-C-RM- 3 �—P !_i
Print Owner's Naine(Electronic Signature) me
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.
L� /ZaOwner's or r\uthorized:4gznt's None(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
(riot registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under NLO.L. c. 142A. Other important information on the HIC Program can be found at
www.tttass.,ovioca Information on the Construction Supervisor License can be found at tvww.mass.,'o3 v/dL
2. When substantial work is planned, provide the information below:
Total floor area(sq. lit.)._ _ (including garage, tinished basement/attics, decks or porch)
Gross living area(sq. tl) _ Habitable room count
Number of ti rplaees Number of bedrooms __-------_--
Number ofbathroom; Nnmberorhalf-baths
j type of heating syslcm . -__ -_ __-- Number of decks/porches
I)pe of cooling sy;lem --------- Enclosed _. Open
i. "Ixal I'nyect Squ:ue Foota,e" inay be sub;tinited t;tr..-f„tal I'Mi&t CLHt" --- - --- - ---
y
CITY OF SiuEm, NWSACHUSETTS
a BUILDING DEPAIM E.�:T
r �r 120 WASHLINGTON STREET,3'e FLO(A
TEL. (978) 745-9595
F.A-C(979) 740-9844
Kl.%(BE RY DRISCOII
1�UYOR T'NouAsSr.PlE.alL3;
DIRECiCKOF PL13LIC PROPERTY/BL:ILDLNG COSL\IISSIONER
Workers' Cumpensatlon insurance Af7Tdavit: Builders/Contractors/Electricians/Plumbers
A f illcant information Picase Print Le ibt
NainC 10usilw.i.Organiratidrvindividual): re-
Address:✓ (� D
City/State/Zip:& ViLI/,— Phone N: e'�'�1
Are you in employer?Check the appropriate hose Type of project(required):
I.0 I am loycr with 4. 0 1 am a general contractor and 1
p oyee:s(full and/or part-time).• have hired the subcontractors d. ❑Now construction
2. 1 In a sole proprietor or partner. listed on the attached.beat.t I. ❑Remodeling
+hip and have no employees These subcontractors have a. ❑Demolition
working ror me In any capacity*
ra workers'comp.insunce. 9, 0 Building addition
[No workers'camp. insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 lain a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.(\o workers'comp. C. 152,§1(4),and we have no 12.0 Raof repairs
insurance required.) t employees.(No workers'
camp.insurance required.) 15•D Other
;Any appilcant Ilia chsvka boa 01 mutt atw 1111 out the%%floc bdoaf show(ng their wmkan'eompanurlun pulley inarnnollma
I4wonawraars who sulintit this affidavit indieaina'hay an da(ng all work and that him"'lid,coninstm must mhmh a new anldavil Indieadng melt.
:01RIrxton that flask this box meet an"had an add(Iiunul+ben showing the nwne otthd mdetlnlraalara and(hair worsen'mmpt policy inranaefoe.
l ern an employer that Is providing workers'comptorsadoer insurance for my employers: Below/s/Ae Polley and Job site
infornrallon.
Insurance Company Name:
Policy 4 or Self•ins. Lie. 0: Expiration Data:
Sub Site Address: Id Y 6X deaCIC17— Cily/Statedzip: .s/1(�,,m
\Itach a copy of the workers'componsatioo policy declarallan page(showing the policy number sad expiratloa data).
Failure to secant coverage as required under.Suction 2!A of&IGL a 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 anil/ar one-year imprisonment,as well as civil penalties in the farm of m STOP WORK ORDER and it fine
of up to $250.00 a day against ilia violator. lie advised that a copy of this slatcmunt may be Purwarded to the Otlica of
Investigations ui the DIA for insurance coverage vcrificaliun.
1,10 iu y r Iffy far I/ pa suit e t thler prrJury r/rut eke hrfunrruffon provided a eve is tr a and correct
c
elx
UJ)iciul nee dell( Dt nor mile in drlr urru,to be conrpleldet by city ur Iuwn n/J1r/a[ !
City nr'1'uwn: --Perm
! Issulog Aulhurily (circle one)!
1. 13ourd of IN-Ah 2.Iluildfm; Deportment .1.Citylrown Clerk a. Electrical inspector 5. Plumbing Inspector
Contact i'crsnnr -... .... Phone II•
CITY OF SOUL ENI, ;tiLkSS:ICHUSETTS
t3L'ILD4\CDEP-AIU IE,VT
120 WASHLNGTON STRE "�• n ET, ] FLOOR
T EL (978) 745-9595
iC!\iDERL.EY DR7SCOLL FAA(973) 740-9344
NLAYOR Tkou tis ST.PIERRa
DIRECTOR OF PU13UC PROP ERTY/HCILDNG COSLtittSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5
Debris, :uid the provisions of IMOL c 40, S 54;
Building Permit k 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 MOL c
111, S 150A.
The debris will be transported by:
e ��c s�� fob t✓
(name of hauler)
The debris
�will
�be/disposed of in
t
n (name of Facility)
(aiitlreS.S OF I�Clhly)
C
- signature ufpermit applicant
dalC
>✓ �°"v airs Loess, eg
O(rice�t`�o cuusumer OT00R
HOME Ih1PROVEMENT CONTRA Type:
Registration: H710484 .yaAnership
Expiration: 10120/2014 ,
'OLO REMODE,CING, -- -�
RICHARD CERUOLCk �i -/ g e a
-51 KIMBALL AVE �T xas J U�etary
REVERE,MA 02151'�..,„�.yn .
..__
I _...
eo
ellt Of'
Nl ss(chusett"- DepaRegulations .tnt11S[undurdw
1 gourd r% ruction
Consttu(ition Supervisor License
License: CS 28460 s
CERUOLO,`' ' x
RICHARD A �`
51 KIMBALL AVE
REVERE, MA02151;`
Expiration: &26=13
Tr#: 20S23