19 WINTER ST - BUILDING INSPECTION (2) -- The C'ommonwe;dth of Massachusens
Board of Building Regulations and Standards CITY OF
.Massachusetts State Building Code. 730 0I11 SALE\I
-
'UGnI Building Prnnit Application To Construct, Repair, Renovate Or Demolish a Revived flop 'Ul/
One-or Two-Fanul.v Dwelling
i'
This Section For OlFcial Use Onl
Building Permit Number: -- Date Allied: -?
Budding 01111cial(Print Nine) Signal[ Dule
ra SECTION I: SITE INFORIII TION
I.I Pro art A:Idress: 1,2 Assessors Map& Parcel N hers
I.la Is this an accepted street?yes no Map Number fare- Number
I.J Zoning Information: 1.4 Property Dimensions:
Zoning District I'mpuscJ Use Lot Arca(sy II) frontage(II)
1.1 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public M/� Priaatc❑ Zone: _ Outside Flood Zone?
Check ifcs0 Municipal li2�On site disposal system ❑
SECTION2: PROPERTY OWNERSHIPt
2.1 Ownert of Record:
Lhrost,'na hfar to of n St fern -,n d� 01976
N;unc(I'nm) C iq,SWtc,l.IP
9 bt�infcy 6t /
No,
;red Street `17�1- 7Yy-,��7� Chr�s1-on�i. `�tarrohyluw 9mrar-G. �m�
Telephone hmail Address O
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ 1 E.xisting Building IBA Owner-Occupied Repairs(s) EV Alteration(s) 19� Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Spccil'y:__
Brief Description of Proposed Work-:_ Egg- revs w
54 f�� ��ev o*
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S i o ao 1. Building Permit Fee: f Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier —_ _x
1, Plumbing S go 2. O(hcr Fees: S
J. Mcclrmic,d ill\'.\('1 $ List:
S. .\lcciiaoical IFirc -- --- ------- -.___.—... . -
\u+rrassiunl Total ,\IlFecs: S
--
b. Total Project Cost: S Check No. _.._('heck:\nwunt: _ _ Cash \mount:
0 Paid in Full Cl Outstanding Bal:mcc Due:
SECTION S: CONS-I'RUC'r10N SERVICES
5.1 C'onstruction Supcn'isur License(CSL) 3 2 z-
_._ iration Date I.\r
4,7
License Number I
---
\June of('SI. Holder I ist CSt. 1.Pe Vcc 110wO
'I\pe Description
Nu. .wd Slrccl .(1 (�nrcslrieleJ lDuilJin;s,i nt i5,1)00 ut. Il.l
R 11011i1Wd I r?I MIMI Dstellin
Cil)i'aen,Sauce LIP / M1I %lasun
RC R,nNin Cuvcrinjit
µ'S µ'inJuw:md Sidin
- SF Soli)Fuel Ilurning Appliances
�� I huulution
9n�-3�3^2gL 6 Lmail address D De 111,3 on
1'cle bane
5.2 Registered Home Improvement Contractor(HIC) toy 7 4
e� ,.,J ray' 44--Jy IIIC Registration Numlwr Expiration Dute
I IIC'Con,pan) Name or I IIC' (cgistrant Nat ����
6 /¢-2— kit*yf /2 I:mail,ddress
No.mil Street tiro � A-1 yc-f ftd--36g Z?ZA
City/Town.State,ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 ..........8--- No...........17
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
-VPt.rtd-lr.✓
to act on my behalf,in all matters relative to work authoriz d by this building permit application.
Ch rsti✓la #arrrn �{�it
)�17�1 �
Dare
Print Owucr's Nmne(Electronic S,gnalun:)
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 accurate to the best of my knowledge and understanding.
� ti h nw 14 Pr iV-) f✓ ~ t /I7 / 1a
� " � Dute
Print owner's or Authonicd Agent s Nmoe Ih.lcetrunn Signauin) . 0,11- - •rw�0�3'�_
NOTES:
I. \n Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program),will na have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be round at
,,,,,, ,n.,., „ ;; .i Information on the Construction Supervisor License can be found at ,),,, 'dr 'll2. ^
\\'hen substantial work is planned, pro\ide the information below:
Total floor area(sy. 11.) _ ______1 including garage, finished basement attics,decks or porch)
Gross li0ng area(sy. 1l.) ____ Habitable room count
_ Numherol'bedrooms
ths
I`t'peo'r`nt`tingrs`item Xunlhcror'decksms Number tporchesl) \'t
I
ncluxJ I '
1. "f,dal Project Square Footage'man he substirncd liq''futul Project Oust"
° CITY OF S.U_EN1. tiL1SS.ICHUSETTS
BUIL )ING DEPARTMENT
120 WASHIINGTON STREET, 3'a FLOOR
°` TEL (978) 745-9595
F.+X(973) 7-W-9846
KI.,,[BERLEY DRISCOLL
ANYOR THo.%w ST.PIExm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LVISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractorv/Electricians/Plumbers
Applicant Information >> Please Print Legibly
Name(Ilusiiwss.organiratiom[nttividu;ll): /JJ-'^ Ac>c+ s/,,
Address: to 61,ce
City/State/Zip: C4. ,on�/L!fC` 144,:5 Phone fl:_
Are you an employer?Cheek the appropriate box: 'type of project(required):
1.0'Yam a employer with/_ a. ❑ I am a general contractor and 1 6, 0 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 7• E"Remodeling
.hip and have no employees These sub-contractors have V. ❑ Demolition
working for me in any capacity. workers'camp. 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.❑ i am a homeowner doing all work right of exemption per MOIL I I.❑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.❑Other
sump. insurance required.)
Any applicant that chuckr box rl main alto rill out the uctioo below showing their workers'compensation puliry intiumation.
'I Lvnsmwnxe who shorn this aBldnvit indicating they am doing all work and then him outride contra mrr moat submit a new an7davit indicting such:V,wimuns that chuck this box must attachod un addidurml,howl showing rho nwne of the subwumrrctom and their workers'camp.policy infomution.
" 'I utn an eutpluyer that Is providing markers'compensation htrurance for my employees. Below/x du pulley djoh e
informprion.
Insurance Company Name. o
Policy 4 or Scl6ins. Lic. 0: Ls/G./ '— Ge� /_ 36rI r-6 �O2 Expiration Date: lam!2 7
. G
lob Site Address: 19 Ccrc`�if r �/` City/State/Zip: 5a 1k ti
Altacb a copy of the workers' compensation policy declaration page(showing the policy number and expiration dam).
Failuru to securecoverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the t'orm of a STOP WORK ORDER and a line
orup to 5250.00 a day against the violator. Ile advised that a copy of this statement may ba rurwarded to the Off ice of
luvestigaliuos ul'Ihe DIA fur insurance coverage veriticaliun.
Ida hereby certify an er ilid ahis gild pen /rles of perjury that the infurmmlun pravided'obuve iv true and carnet,
Official use otdy. Do out"'fire its Iris area,m be cumplered by city ur town of/iriaL
City nr'fnsvn: Permit/I.Icense 4
Its>uing,\whurily (circle uric):
I. hoard of Health 2. Duildinq Deparlulellt .1.Cilylfnwn Clerk 1. Electrical Inspector 5. Plunlhinv Inspector
6.Other
Contact Person__ __ _ Phone II:
Information and Instructions
>lassachuscus General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,.partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Sclf-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Official
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"ail locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on rile for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial ventwe
(i.e. a dog license or permit to bum leaves ctc.)said person is NOT required to complete this affidavit.
The Off 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.
fhe Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Mce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/die
CITY OF S.V-F.Nf, fNL1SS.ICfjUSETTS
3L:UDNG OEPAR- LSiT
120 WASHNGTON SMAEAT, Jw Rocit
TLL (978) 745-959S
KIAMERLEY DRMOLL FAX(978) 740.9&W
.tiIAYOJt T)iO.w1 ST.PM"A
DIRF.CTOn OP PCBLIC PROPERTY/9t:aZNC CO.%011SS[ONEA
Construction Debris Disposal Affldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the Smte Building
Cade 780 CMR section I 11.S
Building permit M 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 NIGL c
l 11, S I SOA.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility) . .. .
�n vcr
(Jddmr or fJnhty)
+ tlnJrure ofpermrt APP lc+nt
JJro �_
7397'
36" 7., 18.,
397,'F 3T" 6s'
34" 28w" 79
27' 2 3 4 35
V3 43 WIU2R
+µl 621 SSL 24 OISHW (] 1 4OB24 W332424 ,Np 14
� i 11
�I l
V
30.RANGv1 B248S
i
2442 W3024 2442
�. --
.. 24" 30" 24"
V r ±y
All dimensions size designations This is an original design and must Ls,tgnod 12/27/2011
given are subject to verification on not be released or copied unless 2/27/2011
job site and adjustment to fit job applicable fee has been paid or job
vconditions. order placed.
rg dembowski crivello schrock kitl 12-27-11 with All Drawing#: : 0 1/4"= 1'
Y
,11a�sa�lnuclls - 1lc ila rnncpi li( Puplic �;.f ct1
1 l3o;u'd lit huiltlin� Rr_ul:uinlu :nul tit;unl:n'll�
�. Constru�Yion 6up�slrisor Lir vnso
License: C5 40335
RICHARD S DEMBOWSKI
6 ARCHELAUS PL
W NEWBURY, MA01985
p�,,,G_ �y i1r< Expiration: 3 12 712 01 3
('onnninanmr Trt; 13M
qj1 Office of Consumer Affairs and eusiness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 104747
o Type: Partnership
Expiration: 7/15/2012 Trfl 299291
DEMBOWSKI BROS. CONSTRUCTION. _.____-.-.------- ---
Richard Dembowski ----' - - -
6 Archelaus Place ----
W. Newbury, MA 01985 _..__�.__—_---------
Update Address and return card.Mark reason for change.
...... �_:� Address �] Renewal [� Employment _ LostCard
DPG-CAI is 50M.04104-G101216