92 TREMONT ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards SALEM
780 CMR 0
t
/ Massachusetts State Building Code, + Revise �LhIC 2Q,1,�
Building Permit Application To Construct, Repair, Renovate Or DemolishZ��b Oct 2`
A nr
V one-or Two-Family Dwelling
!SFITI
Section For OfFcial Use Only
Building Permit Number:
Date.Applfed
Signature Date
Building Official(Print Name).
ON 1:SITE INFORMATION'
1.1 Propeq,Ad �1 LZ Assessors Map& Parcel Numbers
'r'.-e l
1.I a Is this an accepted street?yes_ no
Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Frontage(It)
"Coning District Propose)Use
Lot Area(sy fl)
1.5 Building Setbacks(it)
Front Yard
Side Yards Rear Yard,
Reyuired
Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§Sy) 1.1 Flood Zone Information: l.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Public� Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHiPt'
2.1 Owner of Record: `t `M r IC I �(yt(� 01110
')me(Pruu) t City,State,ZiP �e� ^Q /sLOM
-D -Teep VN 7� [mail Address
p�
Telephone
No.and Street
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)� Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
14
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materiels)
I. Building Permit Fee:S Indicate how fee is determine):
1. Building $ 45r D ❑Standard City/Town Application Fee
2.Electrical S rAs"DO • 00 ❑Total Project Cost"(Item 6)x multiplier x
3. Plumbing S !�f 000 , 60 2. Other Fees: S
-.-lechmrical -=7 S
List:
5.Mechanical (Fire S Total All Fees:S
Suppression) Check No._Check Amount: Cash Amount:_
—' °� El in Full ❑Outstanding Balance Due:
6. Total Project Cost: S hl
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervi or License(CSL) es- IDS li g (g Doll
.�7_�.-�� I.A� License Number Expiration Date
Name of CSL[folder
EyC
List CSL'rype(see below)
95 Mo f Descr Ption
S ecl U
N� U Unrestncled(Buildings itl0 35,000 w. Il.
Restricted l&2Ftanil Dwellin
Cityfro%m,State,ZIP M Mason
RC Rooting Covering
WS Window and Sidinx
Solid Fuel Doming Appliances
vv
I Insulation
Tele hood - Email address I D Demolition
5.2 Registered Home Imp//r1o1�1u1e-mentContrpctor(HIC) IS5(a82
f K(lr A e— Cn Kr . . � HIC Registration Number Expirlition Dane
HIC Cum any Name or HIC Re istrunt Name /n�ff"� '
a� ar> nPr�u c f sera#TStyt�vf ���C��rkar��•(0
;No.an d Su :t M 9 _IEmail address
own State IP R Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 1511 2$C(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 7u:OWNER AUTHORIZATION TO BE COMPLETED WHEN. "
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
i,as Owner of the subject property,hereby authorize ace�IVP a f rJY Mn LL
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
VQ(-AA W b 2f9 (P
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
contained in this application is trueand accurate to the best of my knowledge and understanding.
uffl-M w /o 0ko
Print Owner's or Authorized Agent's Name(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
(not registered in the Home Improvement Contractor(HIC)Program),will nut have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
oVww nrus eov'oca information on the Construction Supervisor License can be found at www.mas�
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
rype orcooling system Enclosed Open
J. "FotA Project Square Footage'may be substituted for`°Fotal Project Cost"
ry
01
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston, MA 02114-2017
Ulf www mass.gov/dia
Workers' Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /+ Please Print Legibly
Business/Organization Name: L( ec$� q CC`6L' ( csn_5Pv) EL�
Address: jAA- 11r `CPrrn S to
U
q /
City/State/Zip: TeiLi d 1'v, Phone#:
Are you an employer?Check A e appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
Q Z) or part-time).* 6. ❑RestaurantBar/Eating Establishment
2.[d„I am a sole proprietor or partnership and have no �7. ❑Office and/or Sales(incl.real estate, auto,etc.)
/ employees working for me in any capacity.. ...
[No workers' comp.'insurance required] g• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers'comp. insurance required]*
4.❑ We are a non-profit organization,'staffed by volunteers, 11.0 Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box ft 1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box 91.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: M 1\e F Z {, �'nSU fhvteN
Insurer's Address: (11 6r W 2
City/State/Zip: �Qt✓A er
Policy#or Self-ins.Lie.# V(:� t7 1 1 Expiration Date:
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 of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 ajoint 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,construction 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 subdivisions 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 your insurance company's name,address and phone number along with a certificate 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 to 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). 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 bum 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
Boston, MA 02 1 14-20 1 7
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Fonn Revised 02-23-15
07YOFSALF4 MASSAQ"En
BuUXWDlsPANDMrr
uG WAMCMSUW93JDAAas
�,.�r�7�s-ems
HI�BiiIBYDtRE40XL FAX 740LVM
AAYCR nnussrPUM
DAwcwxcFPU=PWIffW1BuU=COWMWM
Construction Debris DispdSdAffidavit
(required Wall demolition and.renovation work)'
in accordance with the sixth edition of the State BuMflff Code, M CUR, Section 111.5 oebd.%
and the provbions of MGL o00,S 54; IkdA g Permit si Is ismied with the
condition that the debris rOmkft from this work shag be disposed of in a pmpe*lberued
waste depos(t facility as defined by MGL c ill,S 150A.
The debris will be transported by:
_Cfe4, ye a 1 fi ntio,� I �C
(name of hauler)
The debris will be disposed of in:
a�Pie� LJmSFe N�a�a�eU.� •
(name of fadiity)
OD f9 C&? d* ca d A
(address of facility)
Signature of applicant
e/
Date
Massachusetts Department of Public Safety
® Board of Building Regulations and Standards
License: CS-109748
Construction Supervisor
ROBERT LECLERG - -
26 MARGIN TERRACE
PEABODY MA 01960
..0 r
Expiration:
I`
Commissioner 07/06/2019
r
( d17-1 �panvmoarcweaJ/k ae oaacfaaet/a
Office of consumer Affairs S Business Regulation
HOME IMPROVEMENT CONTRACTOR
E T'pe: LLC
ign Explratl2n
07/28/2018
9 Creative Crafts erf
D/B/ACreative
i
Robert Leclerc
25 Margin Terrac
Peabody,MA 01 Undersecretary
II
9