96 SWAMPSCOTT RD - BUILDING INSPECTION J
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The Commonwealth of Massachusetts
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Board of Building Regulations and Standards—,616s l ° COF
Q u Massachusetts State Building Code, 780t SAALL OF
u ,ncd Mar 2011
Building Permit Application To Construct, Repair, Renovompein-Alisk
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date'Applied: — 7..¢ (
Building Official(Print Name) Signature
SECTION 1: SITE INFORMATION
1.1 Property Address: n�WA N $(a j} �j 1.2 Assessors Map& Parcel Numbers
I.1a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
—/ Zone: _ Outside Flood Zo '? On
Public Private❑ Check if yesv Municipal
'U" site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwnerl of Rec d `
ca-1ier6irA 1ILq lf'e�t tMuor m \q�(73
Name(Print) City,State,ZIP
q(o W-1 q 7__�►3 o✓�a 9 rrrmrcb.cc�",
No.and Street Telephone Emai Iress
SECTION 3: DESCRIPT ON OF PROPOSED WORK'(check all that apply)
New Construction 01 Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work2: 1n1.f7-Au ✓160v DR)AvAUL PAZ 7770rs1 S l tJ ICnn/L�
N .4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building L$ D o o Building Permit Fee: $ Indicate how fee is determined:
2. Electrical S 00—1) ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6) x multiplier 600vo x '711/si 00
3. Plumbing $ d 2. Other Fees: S 0
4.Mechanical (HVAC) S 51060 List:
5. Mechanical (Fire
Suppression) $ l 0 b 0 Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S (00 006 ❑ Paid in Full ❑ Outstanding Balance Due:
PLrat�s Ct I I S 11 00 0
Ar�00 � /
�A� UED �\�,IZ. qP.0 . �trntr `StTE �Sb
+ 0•12 1 0Z
1 I I q — j y1p�11 ECS -ro G c— e Elm t-f o NL_,\ --
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C G — Olt 0 3-71 q 11 -( 7
TVl D rn k� r% rOo/✓1 License Number Expiration Date
Name of CSL Holder
sem 11 n List CSL Type(see below)
No.and Street rl Type Description
�'G M ,y y�//' 0U Unrestricted(Buildings u to 35,000 cu. ft.)
2'f l/I'"� R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
J 4 0X-)2*C,— I Insulation
Telephone Emai] dress D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Ner Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be ompleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issua 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 '�(AAiM 00-Q„1 e^ h7e,L.2,p �g
to act on my behalf, in all matters relative to work authorized by this building permitapplication.
L
Pri W e I r l onic Signature) a e
1 i�1 9 SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my n• e below, I hereby attest under the pains and penalties of perjury that all of the information
contained in application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) ate
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.gov/oca Information on the Construction Supervisor License can be found at www.mass. ov/d res
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"
The Commonwealth of Massachusetts
DepaKinent oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/organiranonandividuaq: Groom Construction Co. , Inc,
Address: 96 Swampscott Road
Salem, MA 781 -592-3135
City/State/Zip: Phone#-
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with 7 5 4. ❑ I am a general contractor and I 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 7. []Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. Building addition
[No workers'comp.insurance comp.insurauce.t
required.) 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I.LE]Plumbing repairs or additions
myself.[No workers'comp, right of exemption per MGL 12.❑Roof repairs
insurance required.)t a 152,§1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.)
"Any applicant that checks box9l must also fill out the section below showing their workers'=rzq=satioo policy inforrtatlon.
t Homeowners who submit this affidavit indicating they art doing all work and then hire outside mntractats must submit a new affidavit indicating such.
tContrsetors duet check this box must attached=additions]sheet showing the name of the subK tnetois and state whether or not thou entities have
employes. If the sub-contractors have errp]oyees,they must provide their wvrkess'comp.policy number.
ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information.
Insurance Company Name: Hanover Tnsuranne from arty
i
Policy#ouSelf-ins.Lic.#_ WHNA552476 1 Expiration DOA te• 3/10/17
lob Site address: l0 Gi�A�1 Go�} RA , 5'dl�M MA City/State/Zip: D i
Attach a copy of the workers'ctliApeusation policy declaration page(showing the policy number stud expiration date). j
Failure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine tip to$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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance eovera¢e verification.
I do hereby certify under the pains and penafties of
perjury that the information provided above is true and correct
Siena e: Date:
I
i
Official use only. Do not write In this area,to be complete y city or town official
City or Town: Permit/License#
Issuing Authority(circle one): I
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
}�! Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Super%kor
License: CS-040379
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THOMAS GROO#
96 SWAMPSCOTT ROM#
Salem MA 01970' ,
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Wilt Expiration
Commissioner 04/19/2017
1