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48 VALLEY ST - BUILDING INSPECTION The Commonwealth of Massachusetts RE EIVE-DrYOF Board of Building Regulations and Standards INSPECTIO14AL SHWES Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or DeW 0 A CP 2 b One-or Two-Family Dwelling This Section For OfficialJolse Only Building Permit Number. Date pplied: /4.0- s/aa s Building Official(Print Name) Signature Date { SECTION 1:SITE INFORMATION CJ / 1.1 Property Address:7 p iq VCJ)e y ST 1.2 Assessors Map&Parcel Numbers t / l.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 fl) Frontage(ti) 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❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Recordjl ��vv��g 4-+- Zyaw\ � I M 0I9% Name(Print) City,State,Z y � uC,I(V 5t (Pig- A) s9s 5' No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK''(obeck all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s ltcration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Propose o k : ooF SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ U 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/town Application Fee 2.Electrical $ ❑Total Project Cost'(Item6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List:. 5.Mechanical (Fire $ Total All Fees:$ Su ression _ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ I ❑Paid in Full ❑Outstanding Balance Due: rnat ,-46D gt2\ SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Ni ;ck"elJ)Z fecz ��� ?� License Number Expiration Date Name of CSL Holder a ' S f / a t List CSL Type(see below) No.and Street k1j Type I Description D t`q C jrXI C` `6 2 6 U I Unrestricted uildin up to 35,000 cu.ft. R I Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding (,{ G Ci q '� :�"�07 SF Solid Fuel Burning Appliances 901 , ! J I Insulation Telephone Email address D Demolition 5.2 Registered Hom�e I/yytp,,rovement Contractor(HIC) G_3� GZ IF �2 lY b HIC Registration Number ExpOOiration Date HI Copp Name pr HIC R�trant Name yt1 �c Swor tJrn 1,0( 4 and Street �� Cy ` h rt✓WS rood ✓y),I 0 IJ Ns ��I- � 19" _`��Y Email address U[ City/Town,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 sub'ect property,hereby authorize 4�- eJ-e4f to a on m alf n II matters relative to work authorized by this building permit application. Print O er's Name 00trofSignature) Date `SECTION 7b:OWNER'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 a carat to the bet my knowledge and understanding. Print Owner's or Authorize Agent's a(Electr nic Signatur Date N TES: 1. An Owner who obtains a building permit to do his/her own work,or anowner 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 x�ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns 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 half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SALEA MASSAQHUSE M BMDINGDEFARTMENT 120 WASHINGTONSTREET,3IDFLwR 1kL(978)745-9595 KRaERLEYDRISQ7LL FAX(978)74a9846 MAYOR 71KMM ST.PMM DIRECTOROFPUBI.ICPROPERTY/IlUt DMGODMgSSIOMR Construction Debris Disposa/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 c40, S 54; Building Permit t! condition that the debris resulting from this work shall be disposed of in a properrlly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: N- S A- � - -'r, (name of hauler) The debris will be disposed of in: (name of facility) N� iJA CLc)/e-2 III A-- (address of facility) Sign ture f applicants -7 IS Date _ ne &MMV iwWj&0j ante hEffeft _=— — �epr� .e a,f�tRs�FrEdAceideazbs _ 600 wasfzia Si-z& a���,=x�sswg©v/his hlfn —,L�rrr Compeassiften i sbam€aee Afa'd a Dem-NhersICentractordgl 1€tu`ewms/Plmn"ters -offDKC2W., �aD"Matson F-Ism Pint>T§MbW Na-i ne(Businessiorgmizatiom2ndividuai_): / ®Fli2 beao± Ak �t�24—p Address:- g®o 0054tu ,!! �?l e Sd S- $�6a - 6 9y2 Ciip!Siate!�.ip-� �,�,9y�v�, e/SyS� �hone�: Are 310-d an employer?Cheep the appropriate box: Type of project(.•equh-aol- l.❑ 1 am a employer with 4_ `�1 am a general contracror and I 6. ❑New construction employees(full and.='or part-time)= have hired the sub-contractors g ?[j I am a sole proprietor or parmer- listed on the attached y sheet= ❑ Remodeling ship and have no employees These sub-contractors have ❑Demolition working for mein any capacity. workers'comp.insurance. 9. Q Building addition [No wrorkers'comp.insurance We are a corporation and its I0.0 Electrical repairs oradditions required.] officers have exercised their 3.❑ Iamahompownerdoingall,.voz* right of exemption per MGL IL❑Plumbing repairs oradditions myself.[No workers'comp. c.I V—§1(4).and we have no 12. Roof rapaas insurance required.]t employees.[No workers' t4. Oeher comp-insurance require&] applicant Ora chacshogi'l mast also fill amtheseetion belowshomivgthairvru mW compensation Poft information. r 1 fame nmers who n-ubmit this affidavit iadicaunsibey medoinsall work and than hire oulddermaactom noW sabmrtanen al5davitindica ivamch. =Contractors ant cheek this box owstatmched anaddidomrl sheet shooing,the name ortbusnb-commctom and theirwulaW comp.Policy information. ern n e= pJore=that is proridnzg workers'coozwersatiofn huarrmtcafior my esrplmre/e�x Below is the policy and iob she insurance C n .f'l t t1 /-/G�1f�r�J t'/rrf, . (i insurance Company Names ® � - Policy=or Self-ins-Lie \(/C I IQ® / �pitation Date, J a�l Job Sitenddress `!� ` �� CiylStaie/Ztp J�l�e _ttach a copy of the worke-3'colepensathm policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder Section 25A of MGL c.12 can lead to the imposition oreriminal penalties of a fine up to S 1a00-00 andiorone-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to MG-00 a day againsttheviolatoz Be advised,theta copy of this statement may be forwarded to the Ofcs of Investigations of the DiA for insurance coverage verification- I do hemby caV& t7tep pelampes oiperjccy shot Asei dbr-valonProvNed above is tree re-ee car.,ee- Sigttaturr. r✓oicc f�-r,^tt,� Date: Phone:?: t3 Fciei ese oat;. Do nor wrke In Eris ere%to becoanteW 5y cW OF WIM offichar E.itlr or Town:- PermWLleense# lsstung Authority(ch-cle one): 1.Board of zicalc* 2.3ultdin 7Department 3,E".tfyrOwn C3erL 4 Electrtca3laspeebor 5.Plumbing inspector 6.Other contact-Person.- €hone THIS CERTIFICATE IS ISSUED AS A BBATTER OF Bi1FORMATION ONLY AND CONFERS NO PJWTS UPON THE CERTIFICATE HOLDEIL THUS CERTIFICATE DOES NOT AFFIRI1IATIVELY OR mmaATIVELY AARIWD EXTEND OR ALTER THE COVERAGE AFFORDED BY T((E POLICIES BELOWW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING (NSURER(SL AUTHORTFEU . REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOMER IMPORTANT_ If the ceTlTTiraie holder G5 an ADDITIONAL B11St(RED,the nORCy�1aS)must he:®ndOmed- ff SUBROGATION 15 VIfALVED,subject to the Terms and conditions or the policy,cef wm pD6des may require an embirsement A"S1atenenton this cm1licalm does not eonferl(gh(y to the Certificate holderin lieu Ofsoeh endorgnnent(s). PRODUCER 644RSH USA.INC. TWOALLIANOECENTM mung 355D LENOX ROAD.SURE 240D ATLANTA.CA 2UMS mitr BMURER[ AFFORDMB=VHNM RNCS iM492 MED-GAEL15-16 DISUREtA:SfeatltadW3MRa�y 25W INSURED - �ImA10®LBDUIm'AIfS(� THE)AT-HOMESEMCE6.INC. DaSta�Ru: Ims OSA THE HOME OEPOTAT-HOME 5SMCES INSURER C-Seff NCO 23041 289000MBERVIRPARMAY.SURE MD msuRERn- H�mnatll�4RwcmlD r 236f7 ATLANTA.GA 30339 INSURER E- INSIIRTARF- COVERAGES CERTIFICATE NUNISM ATL-06324261 EM REVISION NUMBErT THIS Is TO CERTIFY THATTHE POUGIEO OF INSURANCE LISTED BELOW HAVE BEEN ISSM TO 710E MIRED NAMED ABOVE FOR THE PODCY PF�RN3D INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONOTDON OF ANY CAf4TliltCi OR OTHER OD[SA1�ATr mRnR�PEQc Tp crpEmOD CEFMFtCATE NARY We leeU OR MAY PERTAIN.TrtE U45tR%Rmm A 990FWW BY TIE POLICIES DESCRIBED IIERETN IS SUBJECT TO ALL THE TERMS-EXCLUSIONS AND CONDITIONSOFSUCFIPOUCIES_LMWfS6HONWMAYHAVEBEENREDUCm8YPA1DCL URM ILNN TR TYP'e OFINSURARCE u f PDucyntiBBt do L.u°rs A OeueRALUAanJTY Q0466T714U5 OUD=5 MM12D16 EACH OCCURRENCE S Q.—CM00D X I COIMERCULLGE4BRALUABIl1TY P 1,UID S ,MD I CtNMs7aADE a OCCUR ! LwmCFPO.ICYXS OFSRSfMPE3ROCC MEDEXPAD7um:^aa S EXCLUDED PEILRDNALSATNUOURY S %aw" Os.�mLAOmRR�wTE S lk m.® GS tAGC-REOATEURIIiAPPUESP3t PRODUCTS-COMPA)PA S S 9.0mc O X PoucY 1--1 JH.7 n LOC S B AUTOWITILsLIABILITY 8AP21B6B6X12 03N112Dt5 03101=6 s 1.0madD X ANYAITOALLO y` ;� BODO-YINJURY(Pupers� S �D ` I 1AUTOS EDULED SHFBRSUREDAUf0 PHY061G BODaYINA1RY(Paaemmq s HIREDAUTOS pIOAVOS-0WWW PROPER OE S s UMBRELLA DAB OCCUR PACflOcctnomRCE S EXCESSLUUI CWLIStJADE AGCAEGATE S 4 DED it I ETEEmONS s G ..,eR5cowmamn°N 03111=15 WIOUL616 X at Wcb-IATU- OII(- C ANDENPL°YERSLWEUJW WC01713f4!% 6Y, LD®,GM ANY PROPRIROWPARIPIIiRIr7CECUfNE YTN puL N}L NJ.Vi) WNiIZ015 03ID1QD16 Ps EMNACa�RT S D OFRC IRAVE IXCI.IDebT � MIA wLT1T/73t494 QU012Ei5 WNt2016 1,00g000 INandamryln NH) Ilia BLD®tSE_FA s Irry .Desnm_WuMt 0 MRIPnONOFOPERATONBhew CMMmmd EL LDaR s 7,000,mW D-cSCRIPTIONOFOPEMIMliS1LDCKMtia7VHRCLES(ABaehAORD101.Ad=UWRImdmSchWu CBmm sPmlBMQU Q EVIDENCE OF INSURANCE CERTIFICATE:HOLDER CANCELLATION THDAT-HOMESSMCES,WC. SHOU(DAMOFMMABOVE-UM BEDP=XESSECUMBUMOBffORE DBA THE HOME DEMrAT-HOMEEBjv THE EXP°RKITON nATE Ts@tEOF, NOTICE WML BE OaJV9R® W 2455PACESFERRYROAD - - ACCOROANCEWTIMMISPOLIGYLRLOVRSONS. ATLANTA,GA 20M AIRNOR®ttEPRESBRTATNB DfMaM USA IUM I NanashiMukhetee -IL� i. 01988-2010ACORDCORPORATION. AUt7gbtsleservelL ACORD 26(2010106) The ACORD name and logo ate registered morkB*IAbORD I ' M p�ozaa'atrretr,�� o�C�� r¢�c�tc�elfl� � Office of Oousul er Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Kwachusetts 02116 11, Home improvem.pj- gontraetor Registratimi Y "' "'"='' ' `• Registration: '126893 Type: Supplement Card THD AT HOME SERVICES INC.. :%i;;-: ( - Expiration: 8/312016 MARK NIADNA ----- 2690 CUMBERLAND PARKWAYSUIT "30,0 ::'; ': } ' _-__•�.,_•--- _.__.__.............. ATLANTA, GA 30339 .......... {.,•`:> Update Address and return cord.Mark reason for change. eCA 1 0 20M.05/1/ " EjAddress J Resew a 1 Employment ment �L7 Lost Card r��P yPU/J/I[VIINPff���f��1.��fRiJNf�1[Jl'�✓'1 . 9s,-0fece ofconsumer Affairs Rusincss Regufntion License or registration valid for individul use only OME IMPROVgmr=NT C6NTRACTOR before the expiration date. If found return to: Re istrati Office of Consumer Affairs and Business Regulation B 4M•'.•�2 By3< Type: 10PerkPlaw-Suite5170 Expira.1..g� j.6.�� Supplement Card Boston,MA 02116 i THD AT HOME SERVICE4;,ItJG i THE HOME DEPOTATN,;J,I Wapp.SERVICES MARK NIADNA 2690 CUMBERLAND PARKIWiy S h%5I ffl%GA 30339 - Uodersecrerary r iptvalid withou siguature I I f M - <.n I P k , � ; I � 'v �.G: L x, , ; 45 � � T`(' � Y�� 'tea � / Pp1 M1-. � y � �� r r�" ti� ft5 f���� t � � Q� 4 M�. �.I upa I:: ��`' 'x�l,' r �y, �, � ;� ;;, �� � v ;:> . �,I t � I BO i '�:�. ilY �' ..�, wP� ,.:� a ���'� tom` 4J Ye F A�'. ..I AF ��r :! .Q 6,� "I l! � �, �d� - 7� ��d� .. I d ��'. t� >dti f � i ? � �: w� yMr i i� y4°a ��� �:, eV�y � � 5 1 .Y A p �' r 'yP+ I sr f � �w �11 I l5� �� ur4� Y ,,,5555< 1 13 � lfj � �5 �'�� 7 ���V 5 ��x ,r�� a y��� ��� � �� (5 v;t� � i a ''t�"ryy��i�' S�5i5 dr��''�Pi$k� yb n � ( '��ar° ,1�^ f5gVI � � '�ty±y 5�. ��451 6'(� r - ... 1 t-; n r n a>.V�5��:7> F � I