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23 PURITAN RD - BUILDING INSPECTION (2) (-I 3 3'1 'fheCommonwealth ofMassachusetts rDEC — � Board of Building Regulations and Standards INSRVICES 0ll Massachusetts State Building Code, 780 CMR RevBuilding Permit Application To Construct, Repair, Renovate Or Demolish a 104 42 One-or Tivo-Family Dwelling This Section For.Ofliicial Use Only Building Permit Number: Date Ap ted: } /o/ Building Otticial(Print Name) - Signature '_- Date SECTION !•SITE INEORivIATION I.1 Property Address: 1.2 Assessors blop&Parcel Numbers 23 AIRMAN Rb Lin Is this an accepted street?yes no Mop Number Parcel NumbLr 1.3 Zoning Information: 1.4 Property Dimensions: "Luning District Propose)Use - Lot Arca(sq ft) Frontage(Il) - I.S Building Setbacks(R) Front Yard. - Side Yards Rear Yard Required Provided Required - Provided. Required Provided t.6 Water Supply:(M.G.1,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Munici al O On site dis sal s stem O Public 0 - Private 0 - _ Check If es0. -_ p pO y PROPERTYOWNER$HIPI SECTJ[Owi. , 2.1 Owner'of Record: :r6w E n li/tER .S,9aA, ^4- 01970 K"e(Print) _ -City,state,ZIP - 073 ©Mr"77'rfiJ 0 978-7YY,.2DS - - No.and street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all t Is at apply) New Construction O Existing Building Owner-Occupied Repnirs(s) O Altemtion(s) O I Addition O Demolition 13 Accessory.Bldg.C3 NumW4P12AT/40N Brief Description of Proposed Work': �n1tU TE rT/c d EXTE2/09 f!/YN_IS 4Vl7N Ri�r�+Al CEL(t7LDSLt SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: I Official Use Only Labor and Materials) I. Building $ / 0 oa 1. Building Permit Fee:S Indicate how fee is determined: O Standard City/Town Application Fee 1. Electrical S ❑Total Project Cosh(item 6)x multiplier x 3.Plumbing S 2?Qther Fees: S d.10cchanical (tIVAC) S List: 5.\fee hanicaI (Fire total All Fees:S Su rcssiun) ad Check No._Check Amount: Cash Amount: G.Total Project Cost: S i f oo. ❑Paid in Fall ❑Outstanding Balance Due: SKUs TD CmtJ i 12-1 S SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) GS-mg756 /_ /,/ 7 Bmh �4ci kC License Number Expiration Date Name of CSL HolderU ,, .` n� List CSL"type(see below) /S mg l tLl'� `w -Type - Description . No. ;rod Street OO U UnrestrictedBuildin u o to 35.000 cu. Il. //J� IEL� �.�• a�Ot�� R Restricted MEFamil Dwellin City/town,Stale,ZIP M Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances dry syr�8�9 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) //0 SJ _ 57-1WA C01d FP)G%AJC r�D - HIC Registration Number Expiration Date MC Company Name or HIC Registrant Name 37b ('✓ncfllA)Gr6 ) SY No. ajul Street Email address � At . mA, aary�' _617s2-2-al Ci /Town State ZIP Tele hone SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L a 152.§2SC(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 Isitut ce of the building permit Signed Affidavit Attached? Yes.......... No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN• OWNER'S ACENT OIf CONTRACTORAPPL(ES FOI!BUILDING.PERMIT' 1,as Owner of the subject property,hereby authorize S7/CC�1 l"dA/J� • �O t9 act on my behalf,in all matters relative to work authorized by this building permit application. P6 w •r's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this plication is true and accurate to the best of my knowledge and understanding. BRAD DftNilFf /2 3-1.5� Print Dwner' or Authorized Agcnt's Name(Electronic Signature) Date NOTES: I. 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 W_I have access to the arbitration —• program or guaranty fund under M.G.L—.c. 142A.-Ot Other Important infonnaTian on the H1C-PPogramcan be fot�nda-t- www m;nss.covloea Information on the Construction Supervisor License can be found at www.mass.eov'dns 2. When substantial work is planned,provide the information below: 'total floor area(sq. R.) N (including garage, finished basementlattics,decks or porch) Gross living area(sq. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches "rypeofcoolingsystem Enclosed Open 3. "Total Project Square Footage"may be substituted for"'total Project Cost" rillJill oil DO I The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvesdgadons . UIP 600 Washington Street Boston,MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aimiicant Information Please Print Li 'blv Nane(Business/Organization/Individual): J77ta /`htll7�4Y!7iA/� Address. SA /VA.f&ff&7ZW r7, City/State/Zip:/MLA,W ad. iu///,# Phone#:_ 9/7-fV- a/9 Are you an employer? Check the appropriate box: Type of project(required): 1.VII am a employer with_ �Z 4. 0 I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t ?• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp, insutmlce. 9 ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required) officers have exercised their 10.0 Electrical repairs m additions 3. I am a homeowner doing all work right of exernption-per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c 152,§1(4),and we have no 12.El Roof repairs insurance required.)t employees. [No workers' camp.insurance required.) 13.❑ Oche •Any applicant that cheek[box al.must also fil[oof the se[:tim below showing Weir wortsrs'catapensa in policy inamnation.' ' t Hco erwom who submit this affidavit indicating Buy are doing all work and Wen hie outside mnaactms mot[submit a new aSdavit lodiating such. tConeactm that cheek Win bac mart attached io.additiwW sheet showing the name of the sub-coomepma and their work=*camp policy i[tFmmatim. lam an employer that is providing workeir'compensation insurance for my enTLoyees. Below is the policy and job site information . InsuranceCompany Name-.2-01(4/ Aff"Ie" Policy#or Self-ins.Lic.#- 1 Z�#lf 9N/[/3„Z/0 Expiration Date: Job Site Address: 23 Pi/RlT" P-1) City/Statvzip: SAS /0 Attach a copy of the Workers' compensation policy declaration page(showing the policy number and expiration date).' Failure to secure coverage as required udder Section 25A of MOL a 152 can lead to,dte imposition of criminal penalties of a fine up to 81,500.00 and/or onewyear imprisonmes14 as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 8250M 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. r do hereby eerdfy,under th�eJpaim and penaldes ofperjury that the information provided above is true and correct Signature;_ b�e�/`f• Date - Phone FWalonly. Da not write in this area,to be completed by tdry or town qb daL n: Permit/Licenseority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son• Phone#: 4 G _ �esetts�+o�niwr II KAMM ROAD - w NA 080 8103VAIT _ Unrest t:t zdg- of wT use geoup vAdch c m 35,OWaAbw feet(991®')Of etdowd wm _ Fore to aumpardedition oftheiMassachuWm state salon Coda g6m for revocation of*As license. Fm OPSIT 'b t wwo.MessbOWM .. ��- . `�r>,+rr xrrrl,rr rt r rr�+�� r� l� l�r�ir.�a�rr•�rrt�rff.� • ,�-��f, ' ' Office of Consumer Affairs and Business Regulation r 10 Park plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Re9n: 110505 Type: SBPPkMent Card Emphodon: 10P102018 STICCA CONTRACTING CO BRADLEY DANOFF - - - 376 WASHINGTON ST _ ..... . . - MALDEN, MA 02148 Update Addrw and return nrd.Mark reaaoo forte I Addrm I , Renewal ; ? Bmpiopseat ��.� Cord f . ., ..-...' rr« .. I feeaae or re�ritatim vat for ledlvidal nae nary Olfke orCoawWrr Again A Badaera Rr.6dad" 6eforb npitatlnn data If fogad retara ta: .H011E 01PROVE M11T CONTRACTOR pin ofConanmer ARidn and 6ndnea Regulation r.'gyhtratlmc 710605 Type: 10 Park Flat-Suite 5170 Espbvdon: 108112016 Suppbnvffd Card DostmN r4A 02116 STICCA CONTRACTWO CO BRADLEY DANOFF 376 WASHINGTON ST LMA SEK UA 02Ua U ,t Not valid without ai�arin