55 TURNER ST - BUILDING INSPECTION (2) GK i a -7 2 o$
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 780 CMR S
Revised dMar Mar 2071
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Q Building Permit Number: Date Appl' d:
1 Building Official(Print Name) Signature .Date
n SECTION 1: SITE INFORMATION `^ 6
------------
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 9 y .
iut &6l si- , . o
11 I 1.1 a Is this an accepted street?yes no
1.3 Zoning Information: 1.4 Property Dimensions: �Map Number Parcel Number o' j r+j
t
I m rn l
Il_ �
Zoning District Proposed Use Lot Area(sq ft C.) Frontage(ft) _C
1.5 Building Setbacks(ft) -0
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 L9-� Private❑ Check if yes❑ Municipal 13-On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: /
Jbks / Z r v n ok i s�.l4erc MY O C 'k 7 d
Name(Print) City,State,ZIP
.S S Di v vwe 5 7,f/632 691y J
No.and Street Telephone ' Email Ad s
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction El Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)}4G Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ /7el, 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost?(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical 14VAC List: ���
-3—.Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 7 Pd® ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
040 (o`Y6
17b`ww ffW�`w License Number Ex ratio ate
Name of CSL Holder 0
6e A'400 T r S ^� List CSL Type(see below)
No.and Street J u v r{ Type Description
Unrestricted(Buildings up to 35,000 cu.ft.
JV-GGGAS(iJ "v ` �G� R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
XIK y�� SF Solid Fuel Burning Appliances
C. 1 Insulation
Telephone Email addre D Demolition
5.2 Registered Home Improvement Contractor(HIC) //0 9( .2-k `O 2D
/ o-& HIC Registration Number Expirddon Date
HIC Compa�n yName or HIC Registrant e
La
No.and Str eta / Emol4qdre /
4C
Ci /To , S te,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 ..........AtK*� 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 UZ6,�1 G�p
to act ctn my behalf, -mall--afters relative to work uthorized by this building pe(mit application.
Print O ne rs Name(Electronic i at r ) j Date
SEC. ON 7b. Rt OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
coma in this application is trye and 9ccurate to the best of my knowledge and understanding.
Prin er's or tho ize ['s N e ctronic 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 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
i CITY OF S.-1LEM, XaSSACHUSETTS
• BUI DINGDEP{RTMENT
,t 120 WASHINGTON STREET,3w FLOOR
\ raj TEL (978) 745-9595
FAX(978) 740-9846
KINfBFRi t»Y DRISCOLL
MAYOR TriOAtAS ST.P�RRS
DIRECTOR OF PUBLIC PROPERTY/BUMDING COSMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business:Organi:ationiindividual): ✓�G✓ i�
Address: 44 (�S
City/State/Zip: Z S O Phone #: J'4 r CZ 7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4.p 1 am a general contractor and 1 ❑
6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.t ?•remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9, ❑ Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions
myself. [No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.❑Othet
comp. insurance required.]
•Any applicam that checks box#I most also fill out the section below showing their workers'compenmion policy information.
'I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new,affidavit indicating such.
'Comraemra that check this box must anached an additional sheet showing the name of the sub�commcton and their workers'comp.policy infomation.
I am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and Jab site
information.
Insurance Company?lame:
Policy N or Self-ins.Lied.#//.Je-A3 n/ Expiration Date:
Job Site Address: bLbZ Ur1/1/}� �' Ciry/State/Zip: S�Y4�. `a 0Gf%x1"-
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 S 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 S250.00 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.
/do hereby cerrl and the pal s mid pens of per ry that the information provided above Is true and correct
t ue• �j Date: . /
Phone#: /V� i� - /
OJfcial use only. Do not write in this area,to be completed by city or town offici d
City or Town: Permit/I.lcense#
Issuing Authority(circle one):
1. Board of Ileallh 2. Building Department 3.City/rows Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF S.UHM, N'L-�SSACHUSET B
• Buam[IING DEPARTMENT
• P 130 WASIMNGTON STREET, 3� FLOOR
TEL. (978) 745-9595
FAY.(978) 740-98"
KI\tBERLBY DRISCOI.L
MAYOR T HoNtAs ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMWSSIONER
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:
(name of hauler)
The debris will be disposed of in :
// ! ,Auy-" G,�_
(name of fa rc�lity)
(address of facility)
signs of permit a lica t
ate
dcbri.lffdm
Office orc, umer� al(� o�nessR u
'-E HOME IMPROVEMENT CONT
Registration:g110428 RACTOR
Expiration: •�teYlO/2016 Typed
r KEL Y& < f DBA
COMP .
JOHN KELLYJRh
6 ARBUTUS RD 'T
f SWAMPSCOTT,MA 0Under190D 4-
secretary 1
.j
f
t Massachusetts-Department of Public Safety
Boardof Building Regulations and Standards
Camtructinn Supcn'isur —w '
License: CS-000690 �t
```-i.s r, " �.
JOHN J KELLY - �,r. -
6 ARBUTUS RD
SWAWSCOTT 14fA 01907
!;121 Expiration
Commissioner 12/14/2015
i