6 WALTER ST - BUILDING INSPECTION i
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i The Commonwealth of Massachusetts INSPECFI'M L S °N!y}U$
Board of Building Regulations and Standards
+ Massachusetts State Building Code, 780 CMR SALEM
1815 NOV R*'e!l1fekgO /
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Feundy Dwelling
This Section For Official U54 Only
Building Permit Number: Date,Applied:
-Building Oi))eial(Print Name}, " Sigm�ture Date
I SECTION It SITE'INFORIMATION
1.1 Property Address: Wa e P" 5F 1,2 Assessors Map.&Parcel Numbers
l ( L la Is this an accepted street?yes no Map Number Parcel Number
( (1
1.3 Zoning Information: IA Property Dimensions:
Ie Zoning District -Proposed Use Lot Arca(sq It) Frontage(R)
1 1.5 Building Setbacks(R)
Front Yard Sib Yards Rear Yard
Required "Provide! Required Provided. - Required' ' Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
tsid
ao
ne: Oue Flood Zane?
Public❑ Private❑. - Z — OtsW if e : Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERS llp
2.1 Ownert ofyRecorryr: a -V'_ V11 � C) IQ -7 cS
f .0.'� ^A f,A Q, �IOr),y� s 10-
tmt7 a(Print) -City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSEV WORK=(check all that apply)
New Construction❑ Existing Building 17 1 Owner-Occupied ❑ I Repairs(s) Alteration(s) 13 1 Addition Cl
Demolition O Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify:
Brief Descriptiwypf Proposed lVork=:
K-C' a(noci(2 l< i tv en ., - s P f-t-'; d tp2e
SECTION 4: ESTIMATED CONSTRUCTION COSTS'
Item Estimated Costs: Official Use Only
Labor and Niaterialsl
1. Building S e2, yU) I. Building Permit Fee:$- . Indicate how fee is determined:
�.Electricat S - 13 Standard City/TgwnApplication Fee
❑Total Project Cose(item 6)x multiplier x
3.Plombing S P Pther Fees: S
4.�11tthanicai (tIVAC) S List:
5.A[cc hanical (Fire S
Su ression} total:1li Fees:S
Q. y�t� Check No._Check Amount: Cash Amount:
6, Total Project Gast: S ❑Paid in Fult ❑Outstanding Balance Due:
j Z e�
SECTIONS: CONSTRUCTION SERVICES
5.1 CConstruction Supervisor License(CSL) O 3 VU 0 0 1 .. Z I _ Q t
11
1 it K cly` ..S Dv\ License Number Expiration Date
Name of CSL Holder
S, LA Ve. List CSL Type(see below)
No.and Street } (� TYpc Description
111; Ietrt M fi j g 3 U I Unrestricted(Buildino tip to 35,000 cu.11,
City/Town,State,ZIP R Restricted 1&2 FamilyDwelling
M I masom
RC I Roofimi Covering
WS I Window and Siding
J{
8!��� t SF Solid Fuel Burning Appliances
p I I Insulation
Telephone Email address b I Demolition
5.2 Registered home Improvement Contractor(HIC) V a '/g S- V-cZ 3-1
ikL fA e 0!'l HIC Registration Number Expiration Date
IIIC pmy N ?oar H4C Regis` mt N;une
5fVW ur "
,p . 11q
No.and Street . 611, s oM� M - 6.V ��y Email address
Ci /gown State ZIP Vol!Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G.L:c.132.f 2-SC(6)Y,'
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will,result in the denial of the Isivance of the building permit.
Signed Affidavit Attached? Yes ......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED W HEN'.
OWNER'S AGENT OR CONTRACTOR' APPLIES FOR BUILDING.PERMIT
1,as Owner of the subject property,hereby authorize TSO M.0- Z!ar
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
S oz -t - Co v1 +ra C t— // ' /D
Print Owner's Name(Electronic Signature) _ Date
SECTION 7b:OWNER!OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this•t !'cation is true and accurate to the best of my knowledge and understanding.
cllL/ VfGwcn c I/ � rb -/�
Print Owner's or Authorized Agent's Na re(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who(tires an unregistered contractor
_ (not reeistered in the Home_Improvement Contractor(HIC)Program);will!W have access to the arbitration
progiam ar guaranty fund under M1LG L.c. Id2A.Other importnnillnfaimunon on the HiC Program can be ou ant-
Information
nt-Information on the Construction Supervisor License can be round at tnvw.mass.**ovtd rs
2. Waren substantial work is planned,provide the information below:
Total floor area(sq, R.) 's (including garage,finished basement/attics,decks or porch)
Gross living area(sq. R.) 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 ofcoolhtgsystem Haciosed Open
S "Total Project Square Footage"may be substinned for"ToCd Project Cost"
Office of Consumer Affairs nd Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
i Registration: 112785
_ „ Type: Supplement Card
HOME DEPOT USA INC _ Expiration: 4/23/2017
MARK NIADNA ;
2690 CUMBERLAND PKWY STE300'HM SU
ATLANTA, GA 30339 . ,4 R r
Update Address and return card.Mark reason for change.
SCA i o 20M-05/11 ❑ Address ❑ Renewal ❑ Employment Lost Card
�a �rinurrwrrruarrlJ�o�P/�Loeanc�croc((d -
r, before
of Consumer Affairs&Business Regulation License or registration valid for individul use only
1 ;ME IMPROVEMENT CONTRACTOR before We expiration date. If found return to:
°. Office of Consumer Affairs and Business Regulation
egistratlon 112789_; Type: 10 Park Plaza-Suite 5170
Expiratlon _4/23/201 T Supplement Card Boston,MA 02116
HOME DEPOT USA INC
t
MARK NIADNA -r
2690 CUMBERLAND PKWYSTE30 ��5-=z._t..,;••---
AiJ��cG`Ar 339 Undersecretary Not valid wit out sigoatu v
i
Jul 28 1509:40a Richard Madison 9782770685 p.1
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Massachusetts Department of Public Safety "
Board of Building Regulations and Standards
License: CS-MOOD
Construction Sgcerisor
RICHARD MADISON - -`
3 MADISON AVE 1`' r:` .
GROVELAND MA//0��1�936
(�ZZK lam
.— Expiration:
Commissioner 07/2112017
�a-\_.OfceorConsu rAirairs Business Regalarion ,
EIMPROVE NTRACTOR
-..; gegistrati - Type:
,yyAxpira" n: '329 DBAR.J.CONSTR CTION .
RICHARD DIS -- -
3 MAD IS A
GROVE 01836 Undersecretary ;
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CITY OF SALEA MASSACHLBE M
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120 TA9MC7CNSVMT,3W RLOOR
1kL(978)745-9595.
FAX(978)74D-9846
RrMItF>t1 FYDRISlJOLL
MAYOR 71K►s STYMUM
DntEcrcutcFptzmcrRa sm/BunDmaxmsstoim
Construction Debris Disposa/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 c40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
S'�f�ewsfovNy
(address of facility)
Signat bre of applicant
(c) ` ISS .
Date
-' 9iee a -dam
-rte- Boston,IMA 00211-1
COMPenmflava.'Rai m-gaft Affidevitbus
1��9ic E Inforwaaas ledblv
llaelic(BosincsstOrnnnizatinm2ndivfdudl_ tli.iX4
Address: 0$ 6 a 54A) r�
Ciiyi$tatelZip:� � �� grSS'r Phone J`6s r�r� — �y
A-e Vold aa employe-r?%beck the appropriate ba-- Type of px�qject(re -Rd).
I_Q i am a employer ticith 4. Eg I am ageneral contractor and I s Now coas on
employees(full anddor pact time) have lured the sub-contractors
3.0 I am a sole proprietor or parater- listed on the attached slicer 7- Remodeling
ship and have no employees These sub-contractors have a_ Q Demolition
war( ne for mein anycapacity. ivorlters'comp_ittstrdnce_ 9. Building addition '
(NIo warkers` comp_insurance 5. 0 We are a corporation and its
required.] officers have exercised d1eir MEI i;lectricai repairs oraiditions
3.n I am a liomeonmer doing all work riglit oftuiemphon per MGL I1_EI Plumbing repairs oradtiitions
myself.(No ivorke&camp. c_IM—_§I(4),and we Itave no MO Roafrepaus
insurance'required_] employees_[No workers' to_�t4Nxer / �{��n �V OK
comp_instu mcerequired_]
`=Any applicant tl>.r+i1xL-s hue;'i mitnatso fill imntdicsix3ran heioivs�rsiilgtladrnurkms'mmpcabatian polig ittfatmation
Ham=%MCs,rhewbrnitibis afidarkbdi atinatheyaredoingallumkandtbatlike otodilacamra Misnumahmitanemat5davitmdtcuingmck '
=Cont=1013 11M check WLs Enc tmistanacked aaattdiiiamisha,tskorvrog ihammenfttmn�*^^^,^^�^F amldte&snda:is cemp.potig iarotraeGon
nRt r1-er_nlm•�t?x�ispPara�mg rvoP7�s'rO�AeAsotlan iRs3PaRce,,far Rzi eAxlrlmees �etan!is tlxe nolFcg�iabsite
i�7ar:�rcrtlarx_ n � /'
lustirance Canpn5ydz
Policy n Or SelfM- S-LCa1✓ tl 1 9' .3 C,nT/stsTcrz _ J'3
C� f8 ig ' 2f- �/QVr'7iobSitatddrasr i$rA�
"
I tttach a copy of the emrkeW compensa ior_policy declaration page(sbowing`she poticy wip rite explra5ort date).
Failure to secure coverage as required under Section 25A of MGL c.153 can lead to the imposition of criminal penalties of a
fine up To S 1,500.00 andiorone-year imprisonment as wks11 as ei-A penalties in the form of aSMP WORK ORDER and a fine
of up to Sti0.00 a day argainsttheviolater_ Be advised lbat a copy ofthis Acme+*may be fmi a sled to the Office of
Investigations ofthe DIA,for-insurance coverage veffrcadon_
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tAtxerep_ rte _. fh
le�t±Z55 trtyer7ete +stf✓� jt'3'f f�eit �^ololx�.-mteriabove urrc>eeaad cAe ccs
siaturc. t� °� i< / ��r cln G ate_
phone r
�;r tciert�e AxI>r �a y_az v�a�e trx zhts ere tABec�,ta�feeet>:Fri r�£y�?ar�z o,�
City or rown: PermwLicense#
issuing Authrr —j (cirOletine):
1.3oriM of health 2.Efflulldhrg Deparmeug 3,Cstyt r own Clerk q Electrgid fisspeeator §PlumbRagg laspecter
S Other
Caatact ftson: Phoneit+°.
Dan Batwinik t CCM 3358
r 215 West Canton#4 -
Boston,MA 02116
617.649.6948
I� r2 17
Date
Pay to the '
I Order of Cti• 4 4, ,e V- $ 20 c?o d
xx
Xjc +t _Dollars L1
Banko� f America
For 161..,.1+d; ! � `r rx
1:0 1 L000 1 381: 001,62046328511133S13
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