4 WEBSTER ST - BUILDING INSPECTION j/ --- I'lie Continolme tlth uFMussachusclls
hoard of iuilding Regulations and Standards
Massachusetts Statc Building Code, 780 C NIR ti,\Lli,\I
e„
Building Permit Application Tn C'unstntct, Rcpoir, Rcnovat, r Dcnst HA 1/erisdil.I Lu•_'till
One-or rnvr-Fund)- DivvlCln•ir
This Section For 011icial Use On
Building Permit Number: Date.\ ed:
Building Oliicial(Print None) Signature Dale
SECTION 1: SITE INFORMATION
I.I ljfoparty Address: 1.2 Assessors blsp ds Parcel Numbers
xx KOX57" s7-
I.la Is this an accepted street?yes no Map Nunther Purcel Numher
1.3 Zoning Information: 1.4 Property Dimensions-
/aping District Proposed Use Lot Arco Isq II) Frontuge(11)
1.5 Building Setbacks Ill)
Front Yard Side Yank Rev Yard
Required Provided Required Provided Required Provided
1.6\Voter Supply:(M.G.1.c.40.154) 1.7 Flood Zone Inrormatlon: 1.8 Sewage Disposal System:
INiblie @' Pris-ate❑ Zone: _ Outside Flood"Zone? Municipd p�fS
Check if csG� n site disposal s)xtem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1.Ownert of Record D
�t dti 6.ZL l)lc- O/9 ?0
N, a(Print) City,State.ZIP
.c.G� v��- 7NS-/93S' i7-ycke2zl 1( + eEfr+C� .Cort
No.:u d Street relephone Finail Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Numberof Units_ I Other ❑ Spucily:
Brief D scriplion of Proposed Work': 7a 3G/t5i/ !✓0/!S C'l'W� G� /l'y/T Sl��
�Gfaz£MN�Nh✓+ Ss�.6eF'. TIS J�ER'.s>"� e7✓f�'.✓A4� .e"'2s2 N�TN A
.e 2),PeArVXWe- ANit 7a 7.ysi P%WT �.KrvNDd'
SECTION at ESTIMATED CONSTRUCTION COSTS
Item Estinmted Costs: OMclal Use Only
(labor and Materials)
I, Building S e-zQ 1. Building Permit Fee: S Indicate how tee is determined:
lilsvica{ S ❑Standard Ciry+Tuwn Application Fee
2. ❑Total Project Cost 11
6)x multiplier
1. 1'Iwnhinq S '. Other Fees: S-_ _
1. \Icdi.utic.d ill\ W) S �' � List:
j Vcdianical iF,re S ---- - -- --- -- .._ .. _-. . .-
�u„n•ssion) rood .\n Fees: S
t, l'olal Project Cost: ) Che" No. _ ('lie" \mount: . _.._._. ( •hh \mokim:
?D QqO ❑ P.tid in Full ❑OwsLmJing Nal.tnce Due:
SE("PIONS: CONS'I'RtlCrION .SF.RVI('ES
1.1 ('mistructioo Supervisur License I(SI.I
I lccuee kunlhcr I nrali m l)alu
I IA('SI. I'%Iv IN"helms)._
1')pg Dvicripuun
Nu. and Street
U I InreslridcJ tltwWin n ti l0 1t,UUU al. 11.1
P.unil Dttcllin
coirown,. 15 nc./IV .\I Masonry
RC Rinilin Cutcrin
...—. W'S Windim wd Siding
SF Solid Fuel Burning Appliances
78I-63/-0,3/O _ ✓N'P/c2 @ Gi'I9N/L . Cain. I Insulation
Talc hung Flnail addres.4 1 D I Demolition
5.2 Registered Home Improvement Contractor(11IC)
;R",e/£1L0 eqO IIIC Registration Nuntivr 1?cpirmiun Uutg
ill IC Conlpa, Nome or I IIC l4gislrunl Nmng
No. mid Street Email address
CJAQI3LQi A&D
Ci /i•own, State,ZIP` 'rela hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I52.1 25C(6))
Worker Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atIrdavit will result in the denial of the Issuance or the building permit.
Signed AMdavit Attached? Yes .......... O No...........O
SECTION 7s. OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i, as Owner of the subject property,hereby authorize I.AA I /)/ ;P/6q&&6UV
to act an my behalf,in all matters relative to work authorized by this building permit application.
�—i/'.►w M 97,re.-im 3:19- is
Print Uwncr's Nanie(Elcvlrunic Signature) Data
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the informaliun
contained in this application is tr nd accurate to the best of my knowledge and understanding.
319-/3
I'ril Uisner'for:\udnlrircJ,\gent'sN;unglFkvtrunic.Sign;lwrgl Dulg
NO'fESt
i. .\n Goner isho'obtains a building permit to do his.her oivn work,or an owner oho hires an unregistered contractor
(tut registered in the Hume Improvement Contractor(HICt Program),will nr. have access to the arbitration
program or guarmly fund under\I.G.L.c. 142.A. Othcr impunant information an the HIC Program can be Ihund at
o, i Information an the Construction Supervisor License can be round at tt
2. \\'hen substanlial cork is planned,pros ide the information below:
rotul flour area liy. 11.1 . 1 including garage. Imished basement attics, decks ur porch)
Grows Ii%iog.area l sy. lt.l .__. f lobimble rouni count
Numberol'hedrounis - ..
Nu it cr of hathroouis Nunibcr of hall h;uhi _
I)pe of heating i).lein _ Number of Jecki, porches
I\ItC„I c0Ull llg i\ilalll l IIa IP,gd Opall
l "f oi.11 Projcet 1quarc Footage-than hg ,tih,ititacd fur Project Co,C
^�;.. CITY OF S�
,� 1.[.El�f, 1tiLUS.-1CHUSETTS
r< IJEP.3RI?tEtiT
hCi.. .. 1201Y/:15HLNGTON STREET, 3'FLoort
C TEL (978) 735-9595
IUMBER1EY DRISCOLL RUX(978) 740-9336
,AW AYOR TPIOSLts ST.PIERAS
DIRECTOR OF PULIC PR0PERTY/13L:Mn SIG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section l l 1.5
Debris, and the provisions of tbIGL c 40, S 54;
Building Permit tk 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 b1GL c
111, S 150A.
The debris will be transported by:
eV
(name ut'haulur)
The debris will be disposed of in
5 nt��ft ._. t
(name of Cacility)
(a dress or thcility)
t
signature ofpermit applicant
date —
CITY OF S:U-E.)M$ 1 NSSACHUSETTS
" y , BUILDING DEPAKT�tIEDIr
120 WASHLNGTON STREET. 3'Fi00R
T EL (978) 145-9595
FAX(973) 740-9844
[UMBER EY DRISCOLL
1.tAY01 THoatAS Sr.FrE.QRs
DIRECTOR OF PL•OLIC PROPERTY/811 .DLNG COSIbIISSIONER
Workers' Compensation insurance Affidavit: Guilders/Contractorn/Electricians/Plumbers
lnnilcant Information Please Print Legibly
N;11t7a{l3unilxtyUrynirotiu vindividual): r/�✓ ;ieoe&,l,LO cc.
Address: /3/S
CitylStatcizip:�raBls<✓a6?i Ms, 01993 Phone M: wl-d- -03/0
,%re you an employer?Check the appropriate bast Type of project(required):
I.2 I am a employer with_A 4• 0 1 am a general contractor and 1 6, C]Now consuaction
emplayees(full and/or pan-time).• have hired the subcontractors
2.0 1 am a sale prolide tar or purtne.r. listed on the attached sheet t 7. (31emadeling
ship and have no employees These subcontractors have g. 0 Demolition
working Cur me In any capacity. workers'camp.Insurance. 9. 0 Building addition
(No workers'camp.insurance S. 0 We are a corporation and its
required.) Officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all wark right ofexempllon per MOL 11.0 Plumbing repairs or additions
myself.(No Workers'cump. C. 152.§1(4),and we have no 12.C]Roof repairs
insurancorequired.lt employees.(No workeis, 17.00dter
camp. insurance required.) 11
;Any uppllc:ua aaa chueW box eI mutt also oil uut Iho seetim balow showing their"lairs,compmemlun policy infurmallom
I f,wvuwm"who sufmsil Ws saldavtl indicaing they am doing all wank and the,him outride eanimeaa t,must submit a now amdavil indlotlng each.
:C,to fors that chwit this box most aewhodon 3,Mdunalshse showing the none otthe sutKronlnenom and thab worltem'mmp pulley Infammnae.
I am an enrplayer that Is providing ivarkers'compruradon insurance for my enr slayeese Below is the polity and fob sire
lafarrnallarr,
Insurance Company Name: &T/ep/q %Jv[SU.P®.✓P�' /t7
Policy it or Scl6ius. Lic.n: zLtOt� /79 Expiration Dote: 1/—/,3
tub SiIa Address: ..S WIBS:Vw M-- City1State/Zip: .SA'LFJrI iiaA. Q/rJYfQ
AItach a copy of the svorfren'Molignsatlan pulley deelaratlan page(showing the policy number and expiration data).
Failura to secure coverage as required under Section VA ot•MOL c. 02 can lead to the imposition of criminal penalties of a
line up to S1,500.00 undlor one-year imprisonment,as well as civil penalties in the farm eta STOP WORK ORDER and a line
of up to 5230.00 a day against ilia violator. Ile advised that a copy of this statement may ba forwarded to the offiea of
Investigations ui tits DIA for insuranea covaraga verification.
I do hrreby errdj udn the polar and perraklr perJury/flat(Ae hrjunrro/lmr pravlJad above is true and carves
i01fleial rue only. Do oar wtile is 111r area,to be cumplrred by city ar town n/fir/u[
City nrTuwnt Permitfi.lceme.v
Issuing Aulliurily (circlo unc): - --
1. Ilourd of lieallh Z. fluildimg, Department J. Cilylfnwn Clerk 1. Veetrical Inspector 5. Plumbing inspector �
6.Other
Contact Persno: PAana II:
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 142948
Type: DBA
Expiration: 6/32014 TrlF 223057
J.N. PICARIELLO CO.
JOHN PICARIELLO
395 JEFFERSON AVE
SALEM, MA 01970
Update Address and return card.Mark reason for change.
.... U Address Renewal ❑ Employment I] Lost Card
SCA 1 G 20M-05/11 _- ---—
_ _— e C�nrre rrror¢oerr�/�a vfla5=crc�rr rz '
License or registration valid for individul use only
. oflice of consumer Affairs&Business Regulation before the expiration date. If found return to:
OME IMPROVEMENT CONTRACTOR ice of Consumer Affairs and Business Regulation
`l eglstrabon 142948 Type:
lj
,,, 10 Park Plaza-Suite 5170
,,.r xpirahon 6/32014 OBA Boston,MA 02116
J.N.PICARIELLO CO
JOHN PICARIELL0 _
395 JEFFERSON AVE
SALEM,MA 01970 -" Undersecretary Not valid without signature
Massachusetts -Department of Public S
Board of fety
Buildin ants
g Regulation,ons and Standads
r Cons[ruction Supenen-isur
License CS-W, 8 -
395 JE" AVE
SALEM] 01990 "- c
Ilk
Commission FXPiration
10/01/2014