7 WILLOW AVE - BUILDING INSPECTION (3) > • _ �, _ ---- I'he C'onunonsvcalth oFMassachuxtis
yl Board of Building Regulations and Standards CI IN OF
Massachuselts State Building Code. 780 C'NIR SALE,\I
. lrtriecJ.Uu''tlll
Building Permit Application To Construct, Repair. Renovate Or Denw '
One-ur roar-/iunilt Duelling\,
This Section For Official Use OnI
Building Permit Number Date A plied:
2 /Z
Building Ullicial(Print N;un ) S• Datc
SECTION 1:SITE INFORSIATION
1.1 Property Address: 1.2 Assessors Slap di Parcel Numbers
1.la Is this an acce ted street? •es no Map Number Parcul Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed lJsc Lot Area Isy III Frontage III) -
1.5 Building Setbacks(It)
From Yard Side Yards Rear Yard
Required I'rovidcd Reyuircd Provided Required Provided
1.6 Witter Supply:IM.G.1.e.yd,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposals)stem ❑Check ifes0
SECTION 2: P OPERTY OWNERSHIP'
2,1 Owners Record: ev/,\
Name(Pont) Cil State,• IP
� g�y-i3f�
Nu.and Street relephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Osvner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Nu—titer—of Units_ I Other ❑ .Specify:
Brief Description of Proposed Work=: Su, all 41� S o (<,
/1..• c[! �i n /4 cci / /�r..,c • /' c�•...s G✓', /r c o •,L
SECTION J: ESTIMATED CONSTRUCTION COSTS
Rein Estimated Costs: Official Only
I l.ahur and.Materials) y
1. Building S I. Building Permit Fee: S Indicate how r'ee is determined:
2. iflccirical S ❑Standard City,Tussn Application Fee
❑Total Project Cost(Item 6)x multiplier
J. Plumbing S '. Other Fees: S P — - -- - -
J. \Iech.utic.d i11\.Wt S List:
S. \Icdtanic:d ifire -- ----- --------- - . . .
Stwires;ionl S Total .\11 Fces: S--*--
Check \o- ('heck Amount: Cash \mu ont:
n Tula) Project Cust: S 3,6 ❑ Paid in Fuk ❑Outstanding BaLuice Due:
Al N z /C N,S7
a9
SE("PION S: ('ONSI-RUCTION SERVI('ES
y,l ('onstructioo Supervisur License(('SL) _
I ---- ---- I��,irminn H:uc
�7`O fi Z Z lo� I iccnsc Nulnher 1
Na-ncolL'Sl. IlolJcr ... ) Iist0l.
�9 'I•�p%: Hcscription
No. .mJ�trcct --- l l I4lnstricicJ I lLlildin is ti nl 1S,UUU Cu. IL1
R Rcnlriv ed I l2 F-11 Deellin
_�{,i1 �ci h✓�i_ OIL -----._ . \f Slaion
ry
Cityikn o, Suit,: LIP
KC' Klnnin Cuccrin
q's N'induw,uld Sidin
SF Slid Fuel Ilurning 40411"s
I Insulation
1'ek hone
Email address D Demolition
.1.2 Registered llome Improvement Contractor(t1lC)
D 041 - III(: itcg6tration Ntlalhcr livpinttiun Date
IIIC'Company Name Of I tl('I(CglSlralll saki
y Email address
No. and Strcet /�7$ 30 V• 6%G
city/Town,State ZIP Tcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L.e. I52. 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 .......... 123`� No Cl
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
C �
I, as Owner of the subject property,hereby authorize �� ei—
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print owner's Nwne IElcctronic Signulun:)
SECTION 7b:OWNERI 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 accurate to the best of my knowledge and understanding.
Data
Print Owncr's or:\uthorireJ,\gene's N;unu I Illecuunic Signaalro)
NOTES:
1. :\n Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractur
(nut registered in the Hume Improvement Contractor I H ICI Pragramh will nu have access to thenarbitration
can e f
program or guaranty' Lund under M.G.L.c. 1!'_A. Othcr inlpunant information on the HIC Program can be found at
tt tt,t tl�,p,. �,t .y.l Supervisor License can be found at
Information on the Construction �t!1`t IUJ�• Stet ' l'�
on
2. when substan w tial trk is planned,provide the infui iin ludinglgarage. finished basement attics.decks or porchl
rota) door area 1% R.) . ---- -- Habitable room count
Cross lisingarealsy. Il.l -.... ..... .... . .. Number ofbedrooms
l Nunlberol'tircl lnccs ... _ -- Nunlbctofhall'haths - .. .
Numherol'bathromns , . NumherofJecks, porches
f\peal hefting Syvtein I'nclo,cd
I\pe""'Cooling is etcm
I`roic❑ I,quare l'o„Llge' 111,1\ be itlhstitlltcd l'or"1'otol 'n,ject C'ust"
CITY OF SALE112 1%L1SSACHUSE"ITS
' 13LILDING DEP.IRT\(EN:T
120 WASHLNGTON STREET )'a FLOOR.
TEL (978) 745-9595
F.kx(978) 7 f0-9844
3CI\IBEAL.EY DRISCOLL
�L�Yoa Monks sr pmuz
DIRECTOR Of PCOLIC PROPERTY/AU1 0MG CO\6EIISSIONER
Workers' Compensation Insurance Aff7davit: Dui)ders/Contractorv/Electrici•rns/Plumber$
knollcant Information T \ may^ Pleane Print Legibly
Mona UIn 11nC 4Ur jnq]Ilnh lalhVldll.11 l• v �� P� S cv �/yJ/7
Address:
CityrStatcjZip: ✓C-15 _ s PhuneN: S7
`,re you an employer'!Check the appropriate boa 1tnAjMljQM
prn)cet(required):
I.�] 1 am a employer with 4. 0 1 am a general contractor and 1ow construction
employces(Nil and/or part-lime).• have hired the sub•cantractors
2. 1 am a sale proprietor or partner. listed on the attached / modeling
..,hip and have no employees These subconfractors have emolitionworking tier me in any capacity. workers'comp.inmuonce. ilding addition
(No workers'comp. insurance 5. 0 We are a corporation and itsrequired.) offlcers have dzereiscd their ectrical repairs oradditions
3.0 1 am a homeowner doing all work right oreaemption per MGL mbing repairs or additions
myself.(No workers'comp. c. 152, d1(4),and we have no of repairsinsurance required.) ( omployees. [Noworkers' er
comp insurance myuirou
.wy applla:un uur.haek,bog At mWr ibu flll uw the well"below showing their rekm'rompsnudun putiry mMrmuaon.
I Lvnauwnun who,ulvnif We affidavit indkaing ihey an doing all work and than hire outride eontraerone most rohmh a new allldavil indicting.W14
<l�mcwwn that chavk this boa n W t attuhad an addittunW.beef,huwing the nwno or the sub conrnruae and thalt warken'aamp•puliry inrwmarloe.
/tote an rurpluyo thus Is providing ivorkers'rumpeurotlon hisuruncefor my etnplayeea Below Is the policy and job site
iltfarrnut/nn,
Insurance Company Name: �,++.•, v� ._,a n-3
Policy is or Scir•ins. Lis d:_ 4 k�' 13 ?.3�_4L Eapirutian Dote: G
lob Site Address: U/r Cilyistate/Zip: r,4)"
,\ttacb a copy or the workers'compensation pulley declaration page(showing the policy number and aspiration data).
K61uro to watts coverage as required under Section 2JA of,%IGL c. 152 can lead to the imposition of criminal penalties of a
tin:up to 51,500A0 und/ur one-year imprisonment,as well as civil penalties in the Form of a STOP WORK ORDER and a line
,:i up to S_'i0.(l0 a Jay against rlie violator. Ile adviled that a copy of this a14lemrnt may be lurwardcd to the Otiica of
lorc,tigatiuns�ti the 01A for iniurancc covaragc vcri Beal ion.
/du 6vrrby crnify under the paint rota pe"Uhlre 11 perjary that the infurarudmf pruvided above it Irve artd corrrrt
r
l rr.,e only. /La nor nvitr in Ibis area,rd he cumpleted Sy c/ry ur ratan ojjleial.
or 1'Invn: I'ermlUi icense 3
i (circle one):tl of Il AN '. Iluildimo Ucp:b lwent 1. (ilyi ruwn Clerk J. I'lectrict) htglc0,,r i. 1'lnnlhing Inspector
r
t fern ran:
CM OF S.u.Eaf, NEUSACUUSETI'S
JLLmNG OEP.iR msr
I _'0 W.."mmTON STXW, )1O Rmt
Ili. k973) 141-9591
F,kx(973) 744934d
!U1�F_RL.fiY DRLSCOLL
MAYOR mO.ws ST.PmXAA
Dr"ZTOt1OfA3UCPROPt!1ZTY/St; DNGCONNISSIO.NEA
Construction Debris Disposal Atfidavit
(required for ill demolition and renovation work)
fn accordance with the sixth edition of the State Building Code, 730 CMR section I 11.S
Debris, and the provisions of MGL o 40, S S4;
Building Permit At is issued with the condition that the debris resulting from
this work shall be disposed of in s property licensed waste disposal facility as defined by,MGL e
111. S I SOA.
The debris will be transported by:
yai{(i JI cat ` a• rr n
(name of hauler)
The debris wi If be disposed of in
(name of facdily)
Irddrm orLLt
rJuhly)
�y-
iynJnuea(perm,tipphcinf
Jle l./
J
,
? ..Massachusetts -Department of Public Safety
_ Board of Building Regulations and Standards
a - GmstrucfionSupcni+ur � '
License. CS-062262 +`
`�<v:'i
JOHM T HERSEY' _ 'O i
39 CHASE St,"
BEVERLY IYjA 0191 a
Expiration.
Commissioner _ - -- 11/0412013
i Omce 0A, us mer a rs&B
NO ME IMPROVEM a mess e u a 00
!P Reglstratlon 171107
CONTRACTOR..
Expiration 2%13%2014- TYPe:
Individual
JO HERSEY IT
I
i JOHN HERSEY I"( I '
fir' 3g CHASE ST
MASSACHUSETTS AgSICINED RISK POOL.
:I REQUEST FOR CERTIFICATE OF INSURANCE
Ustrtthis form to ragU&M9 Certificate of Insurance from an Assigned Risk Pool Carrier, ..
i
Please provide W of the requested information, Including the facsimile number(e)of the Person or persons to Whom the .
t;srtlflCste of Itleltfettca should be Issued- If this form is fully and aOcutalaly completed,the Certificate of Insurance will be
i, lsoded afQ�dixtrilluted by facsimile to each fax number pfoVldad below.within lWD(2)business days Of the ceniePe receipt
This Form n*be MSW or faxed to the Assigned Risk Pool Cartier. To obtain each txr W$canted(ntonnBliofl ftttfer b the
i I Hof irsrutaM sedum located in the PrcdUcOr COmmumYy section of theSureau's websita,( LMW-
1 1. Name,addlwfa,'teisphone numbor a d faCalr ile number of the/NS;RED'
I Name:
Melling Addwss: —
I . I
PhyslcalAdyresK
Phone: � ` feq, 1�_Fax:
Ck
i . ;
2 Name,addrS&%tetephone number and facsimile nurnber of tile CERTfI=ICATI HOMER:
Name: i
iviewnio Add%cam,
Physical Address:
_I Phone: _ _� Fax:
! ' 3. Name,addnses, contact pe , telephone number antl/acslmllB n er of the PRODUCER:
� .
Name' ty
,
MalanoAddess: _ u ! T.
i Contact Person:
! .t Phone: Fax:
4. Polley IYuroel)Polley EffocUve Date and Policy ExplradOlI Date
h than one policy term,provide the Polley Number,
}
if a qedlfioate of Insurance is needed for mot
fif(tiWV,s Data and Ezptratbn Date for each policy term.
If V., pWky tia6 not yet been issued, YOU mustattach a copy of the Notice of Assignment
Policy Num�r: z
Effective Date:
��. of �FxplrptlonDate,
i Y, exposure not yet
lei
8. 'lnsth Pool turd itri conditions vl availability)oai add/Donal nform tion(including2fort ranges in carp as avaltab/a t
I
sported to theCWWGr) that will ssslst the carrier in the Issuance of the Oertlf/cete oflrtunlence.
NOTE.
nla naa►ed donal lnasrnd vl thv/polnot
ybe listed on any CerilnNN of Insuranco unless such eddlBone
Ia '
C