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10 WHEATLAND ST - BUILDING INSPECTION (2) The Commonwealth of Massachuset�r�,S p IVEU Board of Building Regulations and Staniar§FECTIONAL SER VICES FOR Massachusetts State Building Code, 780 CMR, 7" edition {{,, MUNICIPALITY Building Permit Application To Construct,Repair,Renov�aTm1C71"Dl'�bi A 22isedJanuary One-or Two-Family Dwelling 1,2008 This Sectio For Official Use Only Building Permit Number, - Date Applied: Signature: Building Co i si /htseebtor of a&dmgs Date SECTION 11:' =WT(ON 1.1 Property A1ddress: 1I 1.2 Assessors Map&Parcel Numbers P, �dLP,--�d/ a 64 1.1a 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 ft) Frontage(ft) 1.5 Building Setbacks(it) Front Yazd Side Yards Rear Yazd Required Provided Required Provided Required Provided , 1.6 Water Supply (M.O.L c.40,§54) 1.7 Flood Zone information:. 1.8 Sewage Disposal System: Public❑ Private❑ - Zone: _ Outside Flood Zone? Municipal❑ n s system ❑On disposal t Check if yes❑ - SECTION 2: PROPHRTYOWNERSHIPt 2.1)lI�Owner of Record:_ Name(PP t) y � Address for Service: Stgna e -Telephone . SECTION 3•DESCRHi'1'I09(a! ', td#6§ED WORK'(check all flat;i pp y New Construction❑ Existing Building D Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ .. Demolition O Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: - Brief Description of Proposed World: SECTION 4:ESCIMAT-ED CONSTRUCTION COSTS ' Item Estimated Costs: Offieial'Use Q»fyu-. Labor and Materials 1.Building $ 1 Bni1 tiigPeimit Fee:$ Tndtcae tiow fee is determined: 2.Electrical $ 4$ ! CitxQbwn Application Fee ❑Total PiojectCost3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ g j�U ❑Paid in Full ❑Outstanding Balance Due: �����. � n6�tedt.�J•� SECTIONS. CONSTRUCTION(SERVICES .; ._ 5.1 Licensed�Constrauctton'Superv�so�(CSL) Ye Lc J[5�,?c- i L c6nse Number Expiration Date Name of CS1,tZHbldFr A C j 1,AtW. k4� A/X1 S IL{y�T XJ ©. 5� List CSL Type(see below) if L - - /n do , Address .i i-•r.; - Description . .0 Unrestricted(up to 35,000 Cu.Ft.) Si ture R Restricted 1&2 FamilyDwelling .. gn.q M Maso Onl .. . 7 ! 9 S S-79 `f/� RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Sold Fuel Bunaim ng Appliance Installation - D I. Residential Demolition - - 5.2 Registered Home Improvement ContractOC"(HIC; G� hnc L l HIC Co{npany Name or HIC Registr t Name - 1, 4, Registration Number - Address .. - 2l (,[ -2,(/114 Expiration Date Si rare Telephone - . . , .. •. .. .. ., .. .. 1ACTION6:WORKZE --COPAMSATION INSURANCE*FFMAVIT:(M C L.c;352. $5C(�jj Workers Compensation Insurance affidavit mast be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the IssuanceZ the building permit. - Signed Affidavit Attached?. Yes .......... No...........❑ : I, as Owner of the subject property hereby authorize to act on my behalf,in all matters, relative to work authorized by this building permit application. Sr lure of.Owner Date ' r�---.... -: . . .. SECTION..Ik .Qt`fAt,IWR.-AILAUJL#bRIZF,D.AJGE1�2',DECLARATION ._ C /�j rP102, Z as Owner or Authorized Agent hereby declare that the statemen and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name C11 Signs a of Own i or Authorized Date . !?+ Si ed under the Rains and enalties,of ... ...:._ ..-.- uq,,,,p.,q,,ay,.., 1. An Owner who obtainsabuiidiag;permit to do his/her own work,or aR 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 and Construction Supervisor Licensing(CSL)can e:foundin 780 CMR Regulations 11 O.R6 and I I O.R5,respectively. 2. When substantial work is planned,provide the information below: - Total floors area(Sq.Ft.) - •(including garage,finished basementlattics,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" f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston;MA 02111 www massgov/dfg Werkets,'• Vmpensplten Insurance Abi4vit ]3udders/Contraae,rs,MectricjansMittmbera AoalisantIniormation Please Print Lemlbly' Nttme(Bue®e9f/fhganii9tien/InQiiddttai):• ;J�rr-a L.��ft.�! @� Address: �'�f�Ai%6 Son `�. 4Prsp)G City/StaWZt¢ f���Ltcf,fn�i✓.�/ Phone#: 97�'�x•3.5� Zgc2, Are ab employer?-. . '.: . . .. .. y Check the appropriate box:. Type of project(retpstretq: I. lama fit :; - 4. ❑1Am s enetal contractor and l P187!rt'w' g 6. []Vewcotntritednn� emplQYas.7fdd apolar pg 4uto.- have"hmid die sub contractors . 2.01artia�sole�ptoplieworparmet� listadoatkoattaehed-sheet�r 7. [,�Rernodeling - ship and Rave rto tin@IoyeEs Them sub-contractors have g..o Demolition working In foe-wadycapacitq. wmkcrs'.comp,insmauce. 9. 0Buildingaddition (Noworkers'.comp.insurance 5. 0 We man mrpmation and its 10:O.Electrical repairsoradditions re*nrbd.) .. - officetshavAacaciged:their - 3 0 I am a.homeowner doing all work right of exemption per MGL I I.[]Plopping mpairs or additions myself.[No workers'camp. c.152,§I(4),and we have no 12.�oof repairs iifsumitEd iootOdI.t .. emltloye8s.[No ivorkets' . 13:0 Other - comp-iqs Imm required.) *Any applicant iMtCloCkihoX14 muaglwgiiouttbeaecttonbdorrstamrina didt otkets•cmnpesatioupolicy intotOudm. t Hottaxtwaeta who sibnat,tha "At indkItI4 they am doing allwotk a id then bye outside arterw rimust subadra 6,w aflibvit Wiaating such: 'Comrades t1tud"t1dshoxcustatbuhed arlddirbmlaM1eetahowingdieevno Oran labannliecmrs wd4wirw rkew-ceiop.poli yio2ntWiem. . lamas_ , smpJoywpmt(sprowdtlrgtwilrefs'compensub(oninsuroneejorn6'ewpioyarS Below fsthepallryandjobsite .. injormadon:,T Insuranca Company Name: /✓G'/Vl - _ - . Policy atrr Selrius,Lid.V. I,S G D f/Irl b'G/r! A/[ ('Y�� "ftintion Date: Job SiteAddtess: ay-taMLAdlf S'n/ir.. A/j PI q CitYBtate/Zip: Attach a;copy of tde Syorltelt'compensation,policy:declaradoupage(showing the, c, number and ration date} B Poll Y � Failtue4o soemezovetb mrSection 25A o vL c.152 can to the, cntaiphies of ae a firm Win$1iMIND aai "one-year imprisonment,as well=civil Penalties m1he fort of aSTIOP WORK ORDER and'.afne ofup to32S0.00 a dayagWM tkt vioWm. Bc advisad'thata copy of this statement ataybe.forwarded-to"theOffice of Investigations ofthof3lAfminsuranzecovemp verification. - Ido hereby cvh1&snu1artkepoin9�"tmddpeadhUs'ojperjury that the injortuadon provided above:isnsirandenrreet. Sienat_��f �S/rY �l�tLfiV Date- Phone#: QKklel use only. Do not mite in this area,to be completed by city or to"gf)Reiat City or Town: PeratitlLiceme It Issuing Authority(circle one): 1.Board of Health 2.,Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i Information and Instructions Massachusetts GeneralLaws.chapter 152 requires all employees to provide workers'compensation for their employees. Pursuant to,this statute;an employee is defined as.":..every person.inihe service of another under any contract of Hire, express or implied,:oraYtfr.written." An.employer is defined.as:"an individual,partnership,association,corporal ion or otherlegal entity,or,any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an Individual,Partnership,association or other legal emity;ernpinying:employees._However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwellia house of agodter who 1 to l;. .emp.oys;persoos- doasauttenanee,eonsviwtion orrepairworkandacb dtvet4ng+hotue or on the grounds or-building appurtenant thereto shall not because of such employment be deemed to bean employer." MGL chaQtar 152,§2SC(Q alao;tates thaP'evary state or[oeaf lieersiag-pgegcy shnllwithhoW the.ivsliagte�or reoeval nice gcense a.pent to operate-s�busfness or tdcomteuertmgdivgsln,{Ge�cgtiosrrealth4y:ArOS eppgeant who li§s"hdt'tifvdatet!acceptahteevldenteofeotbpilnnce with ttie:in+s..;v..•.;eot!er8go.tequiced:,• . Additionally,M(dL etiapf IS2,-§25G(7)states"Neither the cbnmtonwealth nor any of i�.poiltical st!bdivisigns shall enter into any txtnlmct:forflieperfonjnattce ofpablicwork9mtil acceptable evidence oj.compliatrcawith the insurance ,.requirements of this citapur have.been presented to The contracting authority." - -AppMeanb . . . Please,fill-out the wotirers'compensatton affide,vit..eppgtietely,,¢grh,c g the boxes 0 ippb�ip oar man"if necessary,supplysub1co ittrector(s)natne(s).add r*es)and pbone.number(s)along with their cet te(s i mrauae.-Limited Liajnitty CompMes(LLC)nt f irmted Liablhty Partnerships(irLPkwithimesrtployees otherthenAhe meq(lrgts,grs,?ierrSijrequ{red•toyavyvyotker;'GotnRc"Satkon,wsW .er Tf'an .:>r"grLl.Pd6es.Iihve . - ._ employees;.ayolfay.isragttae4 Eeadvisad.thatlftisaf6aavit.naybe.auhmitted2orite:. : ,_ of Ipdgsttiai:. A�'t "#6t'eliHafl�s;7t�;te'�tCo�agt. iY(3a�'a�?e�rteigitiii�attt»a rridafiii�viratiautS be rehimed to the eity or to"that.i ie apolication for the,pemiitor lit ense`is beivg'requesl6d,not the Npinnun ilof - Industrial_Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation.policy...pleasc call the.Departmertt at the number listed below. Self-imuped cwnpagies should cmcr their , self-insumace license number on the appropriate line. City or lbwn Officials Please be sure that the-affidavit incomplete and pruned legibly, The Department hasprovided zspaceartlre bdaom of the iffida'vit for you to fill out inthe'event the Office of investigations has to eomlayou regarding the applicant. Please be•suteto fill in the.permiWceose number which will be used as a reference:uumbet. laaddition,an applicant -.,Ibatmast submil multiplc-pcnmWimnsa applicabons m-::any:.gmen.year,need,only sybmitoneaffrdavit-indicating current Policyinfonuation(ifnecessmy)-andundec.`:`Job Site.Address"the applicant shouldwtite"altloeaume;in (city.or town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicaalas,proof that.a valid affidavit is on-file fot future;Permit&or liccases- A new at'0rlavitmust betilled out each year.Whereas home.owner or citizen is obtaining a.license or.pern it not related many bushrgss.or commercial venture (i.e.a dog Ecense or permit.to bum leaves etc.)said person is NOT required to complete this affidavit.The ice of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate,to.give.us a call. The Department's address,telephone andtfax number. - The Commonwealth of Massachusetts Depattment of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext406 or 1=877-MASSAFE Revised 5-2&05 Fax#617-727-7749 www.mass.gov/dia ` Page No. of Pages •Siding JerryP. LeBlanc PROPOSAL AND ACCEPTANCE •SidingConstruction Supervisor Specialty License •Gutter 9 Atkinson Depot Road License:CS-SL 99633 Restricted To:RF WS •Painting Plaistow, NH 03865 Trot 5177 Expires:10/15/2013 •Carpentry Home (603)382-0817 Home Improvement Contractor •Windows •Snowplowing Cell (978) 835-7740 RExp s:211 6/2 149881 1 41 e PROPOSAL suamnTED TO PHONE DATE 1 Ot STREET JOB NAME le CITY,STAT AND DP CODE JOB LOCATION �3 ARCHRER DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: Y o1fLL� . l Y'L � . Y t w yr c ., nIt na -! C S PTnPOSe hereby to furnish material and labor complete in accordance with above specifications,for the sum of: G A 14 Adel 5J�//11� ow 14(,�a4md dollars($ J rr Paym-nt to be made as follows: All material is guaranteed to be as specked.All work to be completed in a workman- Authorized �L like manner according to standard p ill be s.Any alteration or deviation from above Signature specifications involving charge costs will be executed only upon written orders,and �I u become, expo charge over and above the control. O All agreements contingent,ton upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado Note:This proposal may be and other necessary insurance. Our workers are fully covered by Workmen's Com- withdrawn by us if not accepted within dots. �spensation Insurance. -The above pricm,speciBmtrort and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment will be_made as outlined above. Signature Date of Acceptance � �� Signature r 1 Massachusetts -Department of Public Safety f Board of Building Regulations and Standards h Construction Supervisor Specialty License: CSSL-099633 C.• JERRYP LEBLAN, 9 ATtovv NH 3865 wm Plgistow NH 038� ; '' c ow % . ,,`' ` Expiration 1 011 5/2 01 5 Commissioner Consumer Affairs, muoeasi oes�aa,ation tG, Offite of Cmsumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR - gistratlori: 149881 Type: ti . xplraUon: �2L1016-• Individual JERRY P LEBLANC `1 L r J JERRY LEBLANC 9 ATKINSON DEPOT PLAISTOW,NH 03865 -% Undersecretary i CITY OF S:UL&NI, ;tiL-USACHUSETTS t i 8L11DN'GD EPA III LENT 120 WASHLNGTON STREET, V FLOOR TEL (978) 745-9595 F-Aa(978) 740-9845 I<lJtHERLEY DRISCO[.L ,�L4YO:t T�{oSLiS Sr.PlERRB DIRECTOR OF PUBLIC PROPERTY/BCILOLNG COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CAQR section l 11.5 Debris, and the provisions of INfOL c 40, S 54; Building Permit Il 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 IGL c I 11, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in (narncoFfa� ity) (address of tacilily) I nature of armit applicant �C�4i.ilj.b:r