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20 THORNDIKE ST - BUILDING INSPECTION e � The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CNIR S Revised Mar ar 2011 \(� Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section,For`Official Use Only. Building Permit Number '- Date Appliel" Building Official(Print Name) . 'Stgna re , �`. Date,Tf-. SECTION 1:SITE INFORMATION " 1.1 Pro erty Address: 1.2 Assessors Map & Parcel Numbers 9-0 ��o�� s T- 1.1 a [s 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 yes❑ SECTION2:, PROPERTYOWNERSHIP" 2.1 Ownert of Record: M tL0- ,�irkl Name(Print City, State,ZIP No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF.PROPOSED WORK2(check al[ that apply) New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ NumberofUnits_,�_ I Other- ❑ Specify: of Description of Proposed Work': d "AC u J S / Lo-s s u-9A!l2 SECTION 4: EST INIATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only;., Labor and Materials) I. Building S _ ! Building Permit.Fee $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/To Application City/Town Apn Fe V ❑Total P oject Cost' (Item.6)x multiplier' x 3. Plumbing 2.1 Other Fees: $ d. Mechanical (1IV:AC) S List: 5. Mechanical (Fire $ Sir 2 rL p ecssion) Totat All Fees: IS_ Check No. Check Amount: Cash Amount: 6, '1*44al Project Cost: S — -- — _ j (/Y/`•D t � ❑ laid in Full ❑ Outstanding Balance Dua ___ r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) 1 7 �'�r C A- l Q�e /> ,4 LC(0 L License Number -- Esp ration ate Name of CSL Ilolder �^— Lis / ��,/t t CSL Type(see below) J ✓t/11/11 C Ci �141ZC/— Type Description - No. and Street �e- � � Ut Unrestricted B Famidioly s u el ing cu. ft. _ 2 Y�L�! © aZ � J 1 R Restricted 15e3 Pamil Dwelling City/Town, State, LIP M Masonry RC Roofing Covering wS window and Siding SF Solid Fuel (turning Appliances t f& t� 4 C/ C XU 4 L� a Cd 1 Insulation Telephone 1 Emai !X�l address ` D Demolition 5.2/Registered Home Impr vement Contractor(HIC) �� / Ir ieJA/jD LQ D'" 6 g1 G"G I--V HIC Registration Number E. pirati n [Ate IIIC Compan Noma or FIl` Rcgistr, t/�e 5� g[ nd Street �J/f Email address City/Town, 24 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 .......... 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 /(d G 8),� Aj 19 L Gr/2 146 L to act on my behalf, in all matters relative to work authorized by this building permit application. y> ? Print Owner's Name(Electronic Signature) 1e SECTION 7h: 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. Print Owner's or Autlwrited r\gcnt's Name(Electronie 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 Houte Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. I42A. Other important information on the IIIC Program can be found at www.mass.eov/ora Information on the Construction Supervisor License can be found at tvww.mass.:mv'dy-s 2. When substantial work is planned, provide the information below: Total floor area(sq. ft.) _(including garage, finished basement/auics, decks or porch) Gross living area(sq. tt.) _ Flabitable room count Number oftireplaccs_ Number of bedrooms _ Number of bathrooms Number of halflbaths I'ype of heating system -- fype of cooling systcnt — _---_ Enclosed i. "I-Ohd Project Scill:uc Footage" may be sub,tituted fm -Toml Project Cost" CITY OF S:1LE.M. INLksSACHLSETTS BUMMING DEPART%LF_NT 120 WASHIINGTON STREET, 3aa FLOOR \ T EL (978)745-9595 FAx(978) 740-9846 KI\IBERLEY DRlSCOLI TT MAYOR -IOJG►S ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/BUtLDL`IG COIXMISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers A a ilicant information Please Print Le ibl Nalnc(Busiiwsiorpmint r iorulndividuall: rW u Address: 5—[ 1�1A(1, iftL6_ j4laU- City/State/Zip: /C /Nli 'A- C,, • /ids'/ honeN:72l Q P y V Are y ran employer?Check the appropriate box: Type of project(required): 1. I am a umploycr with 2-1 4. 0 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractor - 2.0 lain a sole proprietor or partner- listed on the attached sheet.t 1. Q�madeling .ship and have no employees These subcontractor have S. ❑Demolition working for me in any capacity. workers'camp.Insurance. 9, 0 Building addition (No worker'camp, insurance 5. 0 We are a corporation and its ,� required,) officer U s have exercised their IO. rslectrical repairs or additions 3.0 1 am a homeownerdoing all work right of exemption per MOL 1 I.Q Plumbing repair or additions myself.(No worker'cump. c. 151, $1(4),and we have no 12.❑Roof repairs insurance required)t employees.[No workers' cump.insurance required.) 13.0 Other ;Any applicam that Owks box rl mutt alwa fill din the snitwa below showing their wurkeaa'comp,nwlun pocky information, I hwaowntrs who submit this aeldavit indicating they am doing all work and then him outside conimetors must submit a new allidavit indicting such. :Contractor that chak this box must attachtd ax addidunul what showing the name of the subconirsctors and that,workers'comp.policy infomu ica, /aim on eatpluyer that Ir provldlitir workeril'compensadon/nsarance jar my emplayetra Below/as thepolfcy and Job site iajormadon. Insurance Company Name: �L� Policy 4 or Self-hm,Lic.fie , Expiration Date: " / Job Site Address: 19 / l��/t-��(r �r Ci:ylstate/2ip:a 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 ot'41GL c. 152 can lead to the imposition of criminal penalties of a rinc 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$230.00 a day against the violator. Ile advised that a copy of this stalemcm may be forwarded to the 011ica of Invcstigmimts of the DIA for insurance coverage vcrilicatiur 1 do hdrr y c au tl o/n m d penal! of perJary that the LrfaratoNon provided ab vs,is tea mtd c orrec6 Phone l: / 4? ` 10 40 /' QJ11cial use mtly. Do fat write in this awry to be courpleled by city or town aIjicial I Cityor'rown: Permita.lcenseX Issuing Aulhorhy(circle one): I. Booed of Ilealh 2.Buildlni;Ilcpurhncsit J.City/fown Clerk 4. Electrical Inspector 5. Plumbing inspector b.Olhcr _... Contact Person: ___._ _ Phoneth 4�r CITY OF SU1 ENf IL�SSACHL'SETTS . i BUILDING DEPAR"I'M&NT 130 \Y/ASHCVGTON STREET, 3"Roo& TEL (978) 745-9595 KINMERIEY DRISCOLL FAX(978) 740-9846 NLWOR TI.10-%W ST.PIERRS DI.REcroft OF PUBLIC PROPERTY/BUanD4G COtpIIS5IONER 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 NIGL c 40, S 54; Building Permit t# 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 I11, S 150A. The debris will be transported by: do SAL- (name of llauler) The debris will be disposed of in (name of facility) (address 'facility) C signature of permit applicant at date dcbn. 11 d•k ' �-x Otr. nEl—l-ITTmarlReines✓sR lan � mHOME IMPROVEMENT CONTRACTOR Registration 110484 . Type:. Expiration 10/20/2014 Partnership C "OLO REMODELING RICHARD CERUOLO . r -51 KIMBALL AVE REVERE, MA 02151i\.�`-s='; Undersecretary . Alasstchusetts- Department of Public Safety Board Of Building Regulations and Standards Construction Supervisor License License: Cs 28480 RICHARDA CERUOLO 51 KIMBALL AVE kL REVERE, MA 02151s �_ L s Expiration: 8/28/2013 ('imunis.iuner Tr#: 20823