39 HATHORNE ST - BUILDING INSPECTION C,K ( 9 (o $3S o
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The Commonwealth ofMassachus REC IV
WBoard of Building Regulations and SMWTIONAL 5ER ICE3ciTY OF
Massachusetts State Building Code,780 CMR SALEM
•�t�e��Sc ��1pp1t ' q //�� �isedNlar2011
Building Permit Application To Construct, Repair,Renu%WcIa oliha
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date,Applied:
Building Official(Print Nam Signature Date
SECTIO INFORMATION
1.1 Propert dd2 Assessors Map&Parcel Numbers
ress:
4A 5 T-
Lla Is this an accepted street?yes no Map Number Parcel Number
13 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSMP'
2.1 OwnerrofRecor
Name(Print) City,State,ZIP
51 )4-PrY- o t2N 9- 57__� �'diT= SloS�9�0
No.and Street Telephone Email Address
SECTION 3:DESCREPTIgN OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied El Repairs(s) ❑ Alteration(s) eAddition ❑
Demolition ❑ 1 Accessory Bldg. ❑ I Number of Units Other ❑ Specify:
Brief Description of Proposed Work'':
�r ,roe fy `U
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ �00.00 1. Building Permit Fee:$ Indicate how fee is determined:
-�
2.Electrical $ 13 Standard City/Town Application Fee
❑Total Project Cose(Item 6)x multiplier x
3.Plumbing $ 2. OtherFees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �`jB�,� ❑Paid in Full ❑Outstanding Balance Due:
fh fit t e-V e0 whir. %V 1z
CITY OF S.U.F_X4 NLNSSACHUSETTS
BUILDING DEPARTNMNT
• + 130 WASHINGTON STREET,Y°FLOOR
dj
TEL (978) 745-9595
FAX(978) 740-9846
KINMERI.EY DRISCOLL
MAYOR THOMAS ST.PMRRB
DIRECTOR OF PUBLIC PROPERTY/BVILDLNG CONMIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �-I + Please Print Legibly
Name(Busine OrganizatioNlndivitlual):. C�� 4 G ��1�!'4'
Address: .`i j 1 L w' v 6'
City/State/Zip: Cv-U_%.o M4 Cr 1 /06 Phone H: ��-5Z7 1� ,Z T
Are you an employer?Cheek the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.[i'f am a sole proprietor or partner- listed on the attached sheet.t y ❑Remodeling
ship and have no employees These sub-contractors have V. demolition
workingfor me in an capacity. workers'comp.insurance.
Y Pat tY• 9. E]Building addition
workers'comp.insurance 5. ❑ We are a corporation and its
req 10.❑Electrical repairs or additions
required.] officers have exercised thew
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'camp. c. 152,§1(4),and we have no 12•r❑Y �LjW Roof repairs n -
insurance required.]t employees. [No workers' 13.t,�Otha/ /t-p/LN escomp. insurance required.]
•Any applicant that chocks box 91 must also fill out the section below showing their worker'compenurion policy information.
t l Inmeowrten who submit this affidavit indicting they err doing all work and than him outride contractors must submit a new affidavit indicting such.
:ronin:Ams that chock this box must anaclx4 an additional shat showing the name of the sub-contractors and their workers'comp.policy infommtion.
/am an employer that lr providing workers'compensation insurance for my employees. Below Is the policy and Job site
information.
Insurance Company Name-
Policy
ame:Policy#or Self-ins.Lie.It, Expiration Date:
Job Site Address: Ciry/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 MCL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 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
Investigations of the DIA for insurance coverage verification.
/do hereby 4mrtify under t pains nd penalties of perjury that the information provided above is true and correct
d
m t ire' Date'
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/I.icense#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person• _. Phone#:
Massachusetts Depprtment of Public Safety
Bttard of Bujlding Regulait
tions antl Standards p`
�irR`,�.,. Construction Supeicisor ';
g,, a
--,"License: CS-097889
F��
\\\ A
? JOSEPH C SPERe� �' 'S.
M7 UNCOLN AVE ¢ j
Saugus MA 01906
d\y_jd�d
Expiration i
Commissioner 02/06/2017
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
-T,qr ti' c . S&jch-nJ Zxc�) License Nmnber E�pirat on to
Name of CSL HoolKlder �/ �,
3g-T L INce`, ) /jy List CSL Type(see below) Ulu N�T�Lr��
No.and Street �"/ T Description
PM 6 a- y" 40
,) Q Q � Unrestricted(Buildings n to 35,000 cu.ft.)
Citylfown,State,"LIP ' / R Restricted 1&,2 FamilyDwelling
M Masonry
RC Roofing Covering
JDf.. 5�E"JE'Aa•t Zl.� WS Window and Siding
Jae TA1A SF Solid Fuel Burning Appliances
�/6J I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(BIC)
SDE(L4�1 L f✓E cc o nV A � // YS
T - HIC Registration Number .pira on Date
HIC Company Name or HICr Registrant Name
- /tye;r _ -.5 E2��'Ze}Q ,�r4+e.
No.and Street Email address
�SA�t Gus MA • d 1 °70
Cit /I'owq State, IP 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 Issuanc f 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 eh.in all matters relative to work auth rized by this building permit application.
nl Owner's Name(E nic Signati Date
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.
Print ONmer's or Authorized Agent's Name(EWyonicSignature; U 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
nmLN .mass.eov/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"may be substituted for"Total Project Cost"
Page 1 of 1
Harry Wagg
From: Craig Massey [cwmassey@yahoo.coml
Sent: Thursday, November 12, 2015 9:59 AM
To: Harry Wagg
Subject: Building Permit for 37 Hathorne Street
Good Morning Mr. Wagg,
Betty Haggerty asked me to email you granting permission to issue a building permit for our
residence to fix the railings on her second story porch.
Please accept this email as my express permission to issue this permit. If you need any other
information, please contact me via this email address or via my cell phone at 781-632-2967. 1
can't be reached easily until after 3pm as I teach at the high school and am in class so email is
probably best if you need more information.
Thank you,
Craig Massey
Craig W. Massey cwmassey@yahoo.com
11/12/2015