30 WINTHROP ST - BUILDING INSPECTION (2) Z 5 ct<. L'12
The Commonwealth of Massachusetts CITY OF
—� Board of Building Regulations an&gii'itd `t '1' �a
N Massachusetts State Building Code, 780 CMRc, , . k Revised MaSALErn2011
Building Permit Application To Construct,Repair, W6N6 2s)t dlkSZ
g One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A 'ed:
Building Official(Print Name) Signature '" Date
SECTION 1: SITE INFORMATION
1.1 Pro ert dre ;M� 7 1.2 Assessors Map&Parcel Numbers
p �� —,J Imo —
L l a Is this an accepted street?yl 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(ft)
Front Yard Side Yards Rear 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 Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownee��' f Record: { yJ� r
. ITID?-h14bo L
Name(Print) City,gate,ZIP
No.and Street A Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check a that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) GrI Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (1-IVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructions Supervisor License(CSL)
� -ZZ)b " -- License Number Expira 'o Da[e
Name of CSL Holder
1��1?1�7� List CSL Type(see below)
No.and Street Type Description
5 'A ♦ U Unrestricted(Buildings u to 35,000 cu.ft.
4 L �- R Restricted 1&2 Famil Dwellin
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered om vem nt Contractor(HIC)
HIC Registration Number Ex it on Date
WeFt—
trant Name
No. Email address
City/Town, State,ZIP I 4D Tele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must b completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu ce of the building permit.
Signed Affidavit Attached? Yes .......... d No........... ❑
SECTION 7a: OWNER AUTHORIZATION,TO BE COMPLETED WHEN ,
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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.
63b6—
Print Owner's Name(Electronic Signature) I Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering mypwrf below,J hereby attest under the pains and penalties of perjury that all of the information
contained in th a he on s true d accurate to the best of my knowledge and understanding.
Prim Owner's or A tho zed ent's Name(Electronic Signature) Date
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.massg .gov/oca/oca Information on the Construction Supervisor License can be found at www.mass.eov/d_ 9
2. When substantial work is planned,provide the information below:
Total floor 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"
CITY OF S.UX.M. 1N'IL-kSSACHUSETTS
• BuumLNG DEPARTMENT
' 120 W ASH NGTON STREET, YD FLOOR
TEL. (978) 745-9595
FAX(978) 740-9W
1GNIBFRi RY DRISCOLL
MAYOR Ti-tomm ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BVILDIING CONWISSIONER
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 # 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 b Y:
P
(name of haulJ)
The debris will be disposed of in :
�
' (name of Mci cility)
(address of facility)
signature of permit applicant
date
dOrivlldoc
Offjc-v OF Corlst_trn�'C Aff-E r3 anG �iLt�L1:» D' iiat101.
10 Park Plaza - Suitt 5170
BOSt0r1, i✓Ia�savhus�tts 02116
Home Improvement:Contractor Registration
P.egis ltafion: 120393
Type: Supplemenl card
J Expiration: 813/2016
THD AT HOME SERVICES, INC.
RICHARD FALLONE
2690 CUMBERLAND PARKWAY SUIJ�c—OUW IEFR�
ATLANTA, GA 30339
Update Address and return card.Mark reason for Chan..
Address Renewal ElEmployment L Lost Card
t f;
License or registration II e Consumer_iFrairs&Business Re;ular"ou before the expiration date. If found r enh
return toul use:
a. o
- ME INIFROVELMENT CONTRACTOR O.� O{-fce of Consumer Affairs and Business Re;uladou
' a istrarion: 8 Type: 10 parlcNaza-Suite 5170 -
` �' 'aupclzm=_nit Ca i Boston.NLk 02115
D AT HOME SERV.k=f.ftt. : -
E.HOME DEPOT A,T HOM SE?�%ICES.
-HARD FALLONE
n
30 CUMBEP.LPa`!D PARKWAY$
{p ,GA30339 Undersecretary tint Iidwl outst;nature
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ROBERT POCZOBUT
172 WHALERS LANE
SALEM MA 01970
02/09/2018
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The COMMOnWealth of;VLassacliusetty
Department of lndustrialAccidents
1 Congress street, suite 1O0
Boston, ttrfA OZ114-2017
www.rnass.gov/dia
vork-r3' Compensation Insurance Affidavit:Eluilder3/Contractor3/glactrician3i?tumber3. _
TO BE FILED WITH THE PEILMIT-MG AUTHORITY.
Antilicant Information Please Print Legibly
NaMe (Business/Organiaatiowlndividuat):
Address:
City{State/Zip: - Phone :
Are you a player?Check the appropriate box:
Type of project(required):
I. tarn aamplayar-+vith z:;" t-,' mptayees(Itll and/or part-time).•
7. ❑New construction
21-11 am a sole proprietor orparmership and have no employees working forma in
st 3, �Remodeling y capacity..[No workers'comp.insurance required.]
3. _1 am a homeoavner doing all mrkm self.. t 4. ❑Demolition
❑ g. y (No workers'camp,insurance required.]
4, tmnahmtccnvcrandwdlbehidn contractors! ypro 10 Building addition
❑. g o conduct elf work on m party. (wilt
ensure that all contractors either have makers'compensation insurance arose.sofa tL F]Electrical repairs or additions
proorietors'Ath no employees.
L
2,❑Plumbing repairs or additions
i.❑[am a general contcacmr and(have hind the;uh-eonhradars tided on the attached shed.
These mh-contactors have employees and have warkem,camp.insurances i.❑Ro eisaits
5.❑We are a corporation and its ol6cers hero exercised their ofezemplian per:MGL Q. 4, ther (7
152,1I(4),and the have no employees.[No workers'camp.insurance required.]
Any aPPlicant that checks box Al1 must also fill out the aeclion tiela�v Yhowing.thetFworker;:.compen;ationpolicyinformation -- --- -=- -
"- - "t-HCimeawners ylio aufidut this a[Trdevitindicating they are doing all work and then hire outride eontaclon must submit s now affidavi(indicating such.
tContmctors that check this box must attachcd an additional sheet showing the tams of the sub,egmracton and state whetheror not those entities have
emptoyees. If the-sub-contractors havi amployees,they must--- id tfieir ivorkers'comp.palicY nwnbar.
f am an employerfhat is provlding workers'eanipensatian htsuratice for my employees. Below is the policy and Job site
Information.
Insurance Company Name:
Policy d or Selfins:Lie g: Expiration Date: /
Job Site Address: Y City/State/Zip:
Attach a copy of the workers' compensat y policy declaratl page(showing the policy number and expi tion date).
Failure to secure coverage as required under MOL c. 152,¢25A is a criminal violation punishable by a fine up to S 1,500.00
and/or one-year imprisonment,as well as civil penalties In the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage vedfic .
if,do hereby cer y nd !l p !t andpenalfles of perJnry[fiat the lieformation provided above Is true and correct.
ature: D e:
Phone lf:
OfJklal use only. Do not write In this area,to be completed by city or town ofJiclal.
City or Town; Permit/Llcense ft
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. C4frown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone N:..
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)V_R.lGES CERTIFICATE NUMBER_ AlLMUMP4 REVISION NUQBBER:d
NIS IS TO CERMFY THAT THE P011CIES OF INSURANCE LISTED 3E1.7W,fAvE 3EEV.ISSln3]TO THE INSIiRm NAMf�"ASOVE FOR THE POLICY PlMCO
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CERTIFICATE NOLOER CANCELLATION
li0 AT-kOM6IGMES,INC.
DBA THE rIOME06'OT AT-HOME SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be�."em L A%3EFORE
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