6 AMES ST - BPA-16-1199 CHIMNEY LINER & ROOFING . ; ,• ` � ion
The Commonwealth of Massachusetts wt* ,Ei}
Board of Building Regulations and Standard&& .r10�iIA_'S. ' t''CITY OF
Massachusetts State Building Code, 780 CMR SALEM
ed Mar 2011
Building Permit Application To Construct,Repair,RenovaNJtg?0iAo1ish4 '
—DOne-or Two-Family Dwelling
This Section For Official Use Only
' Building Permit Number: Date Applied:
9 )0 i 10/1
Building Official(Print Name) Signature uo D to
1
_n SECTION 1: SITE INFORMATION
��I 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
— b AOf\.PS Si
1.la 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(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 OWNERSIRP'
Sit-Lem A 0/ f76
Name(Print) City,State,ZIP
42 A-M t5 S7'
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : C i R Cuxj, YQ C00 t G5j!'rmc.\-k Sh �Cd4f t
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1 Building $ —j c;)-o 0 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ ��
4.Mechanical (HVAC) $ List: ^Jl
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
IC)I1g d yy- �. �t1� mla�l p vo �L— Nov plc�c�o�p
0aa 4`e a
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
lOCs-1��
F�-:�- K >7 License Number Exp tion ate
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
tn Q�p �a '��U (,�`� _ Unrestricted(Buildings u to 35,000 cu.ft.
y
I " ' \ Lk R Restricted 1&2 Family Dwelling
City/ own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Tel hone Email address D Demolition
5.2 Registered Home Improvement Contractor(MC) 19ZL4� o 3
S— <- \u, �[= 5'�ru`E`Uv� HIC Registration Number ExpuationDate
HIC Com any Name or HIC Registrant Name
a Q:n�2t t S't
No.and s�Street M�eEmail address
J�� Nn�. o1�SY �2b I ``t�t`1' [SZ
Ci /Town,State,ZIP 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 Issuance of the building permit.
Signed Affidavit Attached? Yes ......... No...........❑
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
to act on my behalf,in 1 matters relative to work authorized by this building permit application.
/Xil11 S@,ou< Lv l l t
Printame(El ctronic Signature) Da[
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 alicatioonis true and accurate to the best of my knowledge and understanding.
/' l�JIR, It
Print er's or Authorized Agent's Name(Electro 'c Sign )
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an muegistered contractor
(not registered in the Home Improvement Contractor(MC)Program),will not have access to the arbitration
program of guaranty fund under M.G.L.c. 142A.Other important information on the IRC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. oy/dos
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 balf/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"
Stella Construction HIC & CSL License's
Office Of C'onsumerAffairs& Business Rt ufg
4OME IMPROVEMENT CONTRACTOR
Registration; 183449 T
Expiration:
10/13/2017 LLC
-A CONSTRUCTION' RUCTION 8 HOME SERVICES, LLC 2,
82'p ' KERT 8T
VEDr-QD- 'MA 02155 Cs
Undersec'
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ERIK KORTZ x°' AL411 ]r
SI FLNKERT STREET . s
Wdfurd M. A 02135 y
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CITY OF S.1LE;�1 iNLNSSACHUSETTS
BUILDING DEPARr%tivirr
120 WASHINGTON STREET, P FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KINiBERIEY DRISCOLL
MAYORTHOMAS Sr.P[ERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONMEMIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n Please Print I.eeibly
Name(Burines,�Organization/Intlividtnl): 5�P1�y. l c7 J'\S'��vc- •J"1
Address: 9D— Q i nV R )� 5
City/State/Zip: eco Jc�Frnc� CQLIss Phone#: 71k
Are you an employer?Check the approprlat� project j: Type of pro (required):
1.❑ 1 am a employer with 4. I am a general contractor and 1 6. El New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole pmpriemr or partrlery
listed on the attached sheet: 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'camp.insurance. 9. ❑Building addition
[No workers'camp. insurance S. ❑ We are a corporation and its 10-El Electrical its or additions
required.) officers have exercised they
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑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 nt applicathat chtsks box at must also 611 out the section below.s owing their woduas'compenmion policy infomutim
t
1Z.who submit this altldzvit indicting dwy ere doing all work mod thea hire oUKide canrratxors most submit a new andavit indicating such
4-antmwmrs that check this box must soothed an additimcd sheet showing tee name of the eub,,mmctas and their wotkm'comp.policy information,
I am an employer that is providing workers'compensation insurance jar my employem Below is the pulley and fob site
information.
Insurance Company Name, G-� Z+V�SJ
Policy#or Self-ins.Lia#:_ 65 6 O - -1 i t'�-I-2-5f-7 21 (o Expiration Date: 2-1 S, -]
Job Site Address: G A M-K5 5� Sw�-eiv. MCA 0 1c1l() 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 2SA of MGL c. 152 can lead to the imposition of criminal penalties of 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
h- Investigations;of the DIA for insurance coverage verification.
I do hereby cerelfy ander the/pa' s and penalties ofperfary that the information provided above is true and correct
,n•t pre• / i'�
Dare, L[J �.i
I 11 -7
Phone#: "-17
Oficial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other