80 TREMONT ST - BUILDING INSPECTION (2) 2g CtC y3$ Z "I LIVED
SPECt10MAl SERVICES
The Commonwealth of Massacbusets 16 H*4P3 P (: 3
Board of Building Regulations and Standards k1 1SCIPHLITY
Massachusetts State Building Code, 780 ClAIR USE
Building Permit Application To Construct,Repair; Renovate Or Demotish a Pewsea t✓m 2011
One-or Two-Farm!),Dwelling
Ims Section For(Jmclal Use Only _
t Building Permit Number: Date,IippGed:
I Building Official(Print Name) Signature Date
SECTION 1: SITE WFORIAkTI<ON
ll.l I.1 Property Address: �� TREMoN�T ST 1.2 t�.csessors Map&Parcel Numbers
—
l.la Is this an accepted street?yes no_ htap Number Parcel Number
13 Zonhag Information: 1.4 Property(Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.S Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required - Provided
1.6 FWater Supply: ps.G L c.40, §54) 1.7 Flood Zone Information: LS Sewage Disposal Spsiem:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private El Zone:
if yes❑ p
SECTION 2: PROPERTY OVVNERSIYIP'
2.1 Owner'of Record:
/n/LTa/u MIA
Name(Print) Cit}, State,
80 MMIWT S'7 9�8- 7yy-2381
1Jo. and Street Telephone Email Address
SECTION 3: 15FSCIRIPTIION OF PROPOSED WORV (check all that appl7)
New Consmucoon ❑ E;Ssting Building Owner-Occupied Repairs(s) ❑ Alteranon(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other Specify: LIJEATNfR12/'FTYOa/
Bnef Description of Proposed Work'.
AISOLAInE /iMIC F f X7-L-A 461ALI T_iJ-_ 61-04u4/ r / t/ZO 6
SECTION 4: ESTDI 4h.TE%D CONSTRUCTION COSTS
(tam Estimated Costs: - Offichd Lase Ounly
(Labor and Materials)
1. Building S O . du 1. Building Permit Fee:S' Indicate bow fee is deternmotd:
O ❑ Standard Ciry/Towlt Application Fee
?. Electrical $ Q s
Total Project Cos[ (Item 6)x multiplier
3. Plumbing S 2- Other Fees. S }t
- 4-Mechanical (IVAC) S List: U
S. hhechanical (Fire S
Suppression) Iota]All Fees: S
06 Check Ne. Check Amount Cash P mt.mot
6. Total Project Cost: S 3 O9, ❑Paid in Full ❑ Outstanding Balance Due:
teal Lam;
'f
r r SECTION 5: CONSTRUCTION SERI ICES
t 1 t Co ru on'45t�eP4Mr License(CSU
BRAb -719nlyff Cs -i6675-00 _1-,31-/7 Incense)Ju.-Hoer t.;cpsan on ware
Name of CSL Holder
/J r �R/ON n�, List CSL T,,Te(see below)
No. and So get K T}'pa Descripriou
U Unresmcted(Buildings uo to 33.000 cti r)
U/Au�/ELa P�nA. G181f0 Res¢cred 1c 2 Fam It Dwelling
City/Towm, State,ZIPS ]J� h4asonn
PC P-00f no Cave.-iztg
VV'S V indow add Siding
SF Solid Fuel Burning Appliances
/teal 9 Insdladnn
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(EUC) //O `OS /6,20
_/6
S'� L�tWTMG WG' (fn MC RemJstration Number E.piraous Date
HI C Company Name or HIC Reeistr rnl Name
376 L SWIA97on/ sT-
No and treet Email address
City/'Town,State.ZCP Telephone
SECTION 6: iWOF-IaRY CONIPENS/.T➢Ott' ENSUPaNCE' s A@RT (KC..L. c ISI g 25C(6))
Workers Compensation Insurance atndavit must be completed and submitted w'itIr this application. Failure to prordde r
this affidavit will result in the denial of the Issuance of the building permit,
Si-toed Affidavit Attached? yes _--_.._ No........... ❑
SECTION 7a: DM74ER kUE`HOPIZkTION,TO BE COMPLETED V=N
OWNER'S AGENT OR CON'TELACTOR APPLIES FOR BUILDING Pi",RKIT
1, as Owner of the subject property,hereby authorize -5�11CM 'OAJ TA19C7/A/6r CO
to act on my behalf, in all matters relative to work authorized by this building permit application.
Ail 76Al elX &Z 3-3-/(o
Print Owner`s Name(Electronic Signature) Date
SECTION 7b: CPWPIER' OR XTE➢ORIZE➢AGENT➢,ECL_A-RkTION
By enterino mp name below, I hereby attest under the pains and penalties of perjur},that all of the infntmation
contained in this application is true and accurate to the best of my I owledee and understanding.
Print Owner's or Authorized Agent Name(Electronic Sit-a-e) Date
d TES:
I. An Owner who obtains a building perron to do his/her own worlL, 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. )42A.Other important information on the IDC Program can be found at
a vvw mass.gov//oca ]reformation on the Construction Supervisor License can be found at
2. When substantial worle is planned,provide the information below:
Total floor area(sq. fL) (including garage, finished base nendaincs. deck or porch) _
Gross living area(sq. ft.) Habitable mom count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalf/baths
Type of heating system Number of deck/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwea&h ofm=aehusetts
Department of lndustrial Accidents
Offiae eflnvesdgadons
600 Washington S&ed
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Mectr'iciam/Plumbers
An9Hcant Information Please Print Letrlbiv
Name(Busitbdt]rgutimtion/lndividua0 3STl r___mod /'n� f� G8.
Address: 376 wArmiwnw rr.
CitylStatft ip: Phone#: 4/LIT-2- AS/9
Are on an employerr Check the appropriate box: Type of project(required):
1.( I ton a employe with_ `Z 4. 0 I am a general contractor and I 6. 0 New coustruction
employees(full and/or part-time).• have hired the sub-coutcaetms 7. 0 RemodelingZ ❑ I am sole proprietor or partner- listed on the attaches abed
ship and have no employes These sub-cantractots bare 8. ❑Demolition
working forme in any capacity. workers'comp.mswunce. 9. ❑Building addition
[No workers'corrrp.instance 5. 0 We we a corporation and its 10.0 Illeebical repairs at additions
requited.] officers have exercised 6cev
3.0 I am a homeowner doing all wm t right of exemption err MGL I LED Plumbing repairs or additions
mystic No workers'camp. a 152,§1(4)�and we have no Iy0 goof
insurance required.]1 employees. [No workers' 13.0 Other
comp.insurance required.]
'wsy applicmtehuebmia boa#r mmtabo 6r ostibesemon hdow showing Poeire�lres'acoapraooea parq ia�uca'
r tfereeowoaa who abodt mks affidavit they e:e doing di work and am hie omideemlamesrsaarabok a new 8911davlt6 sash
kAntrutoar that dm k this box amsaaodadin Wdtiaot abect:bowing the acne of tha adoommosesm ad Oak workes'eeaep.popsy inr-- an
1 net an earplayer that is providing workas''earep oration insmwree for eaymoployem Below it the policy and fob site
informadon .
Insurance Company Nam= ZuAiw d/f airAhl
policy#orself-ins.Lie.# V a�Ed�'IfB �l�_ &piretionDate:��Jr!
Job Site CityatmerGp: SNZ-A",I14.
Attach a copy of the Workers'compensation polity declaration page(showing the policy number and expiration date}-
Failum to secure coverage as required en do Section 25A of MGL n. 152 cam lead to the imposition of criminal penalties of a
fare up to SIS00.00'11INd/or omyear imprismat®t,as well as civil pc hies bt the form of a STOP WORK ORDRR and afine
Of up to SUM a day against the viotamr. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage:vcifieatimr.
do hmeby ee#fy wader the pains and penalties ofperjury that the iitformadon provided above Is bw and wff _
Simraorm, , 1-4.
F
e only. Do not write in Heir araa,ro be cwnpined by eley or Move o� ciffLwn: PeruritUceosethority(eirde one):f Health 2.Building Deparffient 3.City(Fown Clerk 4.Electrtrint Iospctor 5.Plumbing Inspector
rson• Phone#-
+.lCgmtt9M,n Supertimr'
S ^'S^
BRADLEYDANOFF _
15 MARbDM ROAD
WsLvfidd MA 815fi+e
0113112017
Unrestricted-Band W of any use group which
cocain ka-dap 35,000 cubic Sect(991®')of
endosed spy
failure to(a>ssess a conva edlNon of the Massadiusens
Rate eve ft Code is cause for revocation of this iiceree.
W CPS i7msdnfldernntonvist ww Mass.Gov/DVS
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r+ - Office of Consumer Affairs and Business Regulation
10 Park Plaza. - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 110505
Type: Supplement Card
012016
'Exptration: 10/2
STICCA CONTRACTING CO
BRADLEY DANOFF
376 WASHINGTON ST
MALDEN, MA 02148
Update Address and return card.Mark reason for change.
-! Address I ; Renewal ! Employment f•est Card
' Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
r ,HOME IMPROVEMENT CONTRACTOR before the expiration date If found return to:
• ;.,I Office of Consumer Affairs and Business Regulation
Registration: 110505 Type: 10 park Plaza-Suite 5170
Expiration: 10120/2016 Supplement Card Boston,MA 02116
STICCA CONTRACTING CO
BRADLEY DANOFF
376 WASHINGTON ST
MALDEN•MA 02148 Uodersecrttary Not valid without signature
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