24 WINTER ST - BUILDING INSPECTION (3) \/\
1 OF
The Commonwealth of Massachusetts
V \ " Board of Building Regulations and Standards CITY M
Massachusetts State Building Code,780 CMR S
Revised dMar Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1t1 goo a Address: 1.2 Assessors Map&Parcel Numbers
Lin 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 Yard Side Yards Rem 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 System:
Public Private❑ Zone: Outside Flood Zone? Municipal On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 er of ecord: Sin 1�� t Aa i cl 77 O
acn]e,, 'nt) City,
�State,ZIP / /� 1 /v(�
15
No.and Street Telephone mail Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied 171 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
baI �(enw J,e : 4c
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ !Q,oqa 1. Building Permit Fee: $ Indicate how fee is determined:
�y ❑Standard Ciry/I own Application Fee
2.Electrical S %_060 ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ (f 2. Other Fees: $
4.Mechanical (I-IVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 5�Q ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
/'S 6G z/zuX
?`��' 0, Nam; 1 t License Number
�
Exp ation)Sate
Name of CSL Holder
11 `` List CSL Type(see below)
W n G ec•` J+
No.and Street Type Description
i p U Unrestricted(Buildings up to 35,000 cu.ft.
61t-6y'e-1Q tn.o( MA { U 3 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home ImprovementContractor(HIC) i Q , I ( q 1
1` N r" �11 O HIC Registration Number Exphatioh Date
HIC ComGGaun�y'Narue or HIC Registrant Name
G w n r�n S+. c-,0 V,e; yt=c i rs)vl .vie_r
Np.and Street Email address
C�tfodC.�c.:nv� A bi!9--7:14 7231_01Z7, I`l5
City/Town,State,ZIY 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 Issuan of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a: OWNER HORIZATION TO BE COMPLETED WHEN
OWNER'S GENT OR O TRACTOR APPLIES FOR BUILDING PERMIT
I,as O er of subject pr erty,here y a hori z54
to act o y alf,in all m e r<wyuthorized by this building permit application.
7
Print me ectronic Signs D 2,61
S ION :O Rt R AUTHORI AGENT DECLARATIO
By entering my n ,I hereby attest under the a ties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Prin Owner's or Authorized Agent's Name(Electronic Signature) JDate
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an 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 can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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"maybe substituted for"Total Project Cost"
t
CITY OF SOU ENJ, N'I1SSACHUSETTS
• • &:IIDUNG DEPART\W.NT
120 WASHiNGTON STREET,3w FLOOR
aj T1F1- (978) 745-9595
FAX(978)740-9846
KINIBERI.EY DRISCOLL
MAYOR •I1:iOMAS ST.PiFRRS
DiRECTOR OF PCBLIC PROPERTY/BUILDIING CO%L%MIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Plcase Print Leeibiv
Name(Business:Organizationtindividual): �&%s a-I\ in kl� e-, I\
Address: L Wcoc)i S4
City/State/Zip: T OIg7iPhone#: -781-922, 1515
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ w construction
ployees(full and/or part-time).* have hired the sub-contractors ye
2.ZI am a sole proprietor or partner- listed on the attached sheet. ?- Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for mein any capacity. workers'comp.insurance.
[No workers'comp.insurance 5. 9. ❑Building addition
p ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I l.❑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' 13.0Other
comp.insurance required.)
-Any applicmt ant checks txa pl must alw rill rut the section beiow elbowing tbcr workers'compmsadon policy information.
I I I.wsteawnen who submit this affidavit indicating they ate doing all work and the,hire otmtide centrauors trust"limit a M,v alYdavit indicting such
:Contmeam,that ch ck this boat must anached an additional shed showing the name of the sub•contracpote and their wurkere'comp,policy iakmution.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.# Expiration Date:
Job Site Address: City/State/Zip.
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DiA for insurance coverage verification.
!do hereby certify under7 ,9 lJ/s an niallks of In that the hiformadon provided above is true and correct.
Date: -RZ /
Phone X: ;3/, 92
OJrcief use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/l.iccnse# _ _
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbin]Inspector
6.Other
Contact Person: Phone#•
l _ —
CITY OF S U.&NI, NLksSACHUSETTS
04--iN
BuTI DIING DEPjRT\tBA1T
120 W ASHNGTON STREET,YD FLOOR
TEI_ (978) 745-9595
FAX(978) 740-9846
1j\IBgRL.EY DRISCOLL
MAYOR THomm ST.Pw-m
DIRECTOR OF PuBLic PROPERTY/BUILDING CONMUSSIONER
Construction Debris Disposal 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 c 40, S 54;
Building Permit Al 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 MGL c
111, S 150A.
The debris will be transported by:
CO' I\I e--; I
(name of hauler)
The debris will be disposed of in
(name of facility) ,//4_ihiy �
(address of facility)
6
signature of permit applicant
off. 7�`3
date
dcbri.u1TA e
>lie P��o�r s� 14A� eC>ta
Office of Consumer Affairs and ffusiness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Co tractor Registration
Registration: 149797
Type:- Individual
Z a Expiration: 2/9/2014 Tr# 22f469
RUSSELL ONEILL W
RUSSELL ONEILL
38 GROVE STREET
LYNN, MA 01905 q ��
Update Address and return card.Mark reason for change. -
❑ Address Renewal Employment ❑ Lost Card
DPSCAI 8 50M-04/04-G101216
office o�oosume' Tai�is&kuine`"ss-S2egofao`rt License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date.-If found return to:
Registration: �y149797 Type: Office of Consumer Affairs and Business Regulation
Expiration: 2/9/2014 Individual 10 Park Plaza-Suite 5170 F-4 _=.___ Boston,MA 02116 - -
R LL ONEILL'7
RUSSELL ONEILL -_ PI -
38 GROVE STREETS i—� Z
l
LYNN,MA 01905y l Undersecretary Not valid without signature
1 Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supenisor (—
License: CS-0928-09282
RUSSELL ONEILI:
38 GROVE.STREET p
Lynn MA 01905 = ���(�(`
'` Ajf1'� Expiration
Commissioner .02128/2015