27 BARCELONA AVE - BPA-12-226 REMODEL KITCHEN �`j7 lay (K wig
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
r
�n Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Y
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D Applied:
4
Building Official(Print Name) Signaturov. Date
SECTION 1:SITE INFORMATIO
1.1 Property Addrep��: 1.2 Assessors M &Parcel Numbers
V or
1.Is Is this an accepted street?yes_— n o_ 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 ifyesB,� Municipal ZY16n site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owpert of Record:
�a4'. liur�coc✓s r 96t i-P wl $44
Name(Print) City,State,ZIP
97 130rtClo"J! ' Fly PS7 a37/
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) WTAddition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work=: /',0 a R.a a oaC In m Ca 1A,4
G tr w U n G cv OJ re
•SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ IC V &c2 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ Z v&-0';j
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ / 06V, oU 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ i-7 /UV 4�0 ❑Paid in Full ❑Outstanding Balance Due:
Ids' ;! �0
' SECTION 5: CONSTRUCTION SERVICES
5.1 Construction SSupervisor Li se(CSL) C�• i(e ���l 3 / 2U/Z_
��1A //fie ,>/�` License NumberExpiration Date
Name of CSL Holder
List CSL Type(see below)
Now. Jana Streett •. 7` d Type Description
�''Phy�P']�L✓hI • M/l �j�i��J� ' - U Unrestricted(Buildings up to 35,000 cu.ft.
l R Restricted 1&2 Family Dwelling
City/Town,Sfine,ZIP M Masonry
RC Roofing Covering
ws_ _ Window and sia;n
(J c -7.7 ,t p�1 n_ / SF Solid Fuel Burning Appliances
/ /� 4 �j� /l�r/G���`clN1�/C'G17iilf?� I laculation
Telephone Email address D Demolition
5.2 Registered Ho a Improve Con tractor(HIC)
Ale, 2
cI
sat Name rati6n Number Exp
iftifion Date
ifye1anC ��gi 1i'm.9-c: 9;7f- L'.aweQr/,.+s.,o.�
N d Street Q]�, �,7/ Email address
(ced';-'e yWnO 01��-3 / 6 Z&—
Ci /TowTir 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 / // Gl s6�iI
to aff on my behalf,in all matters relative to work authorized by this building permit application.
Pr�mt Owner ame(Electronic Signature) Date
SECTION 7b:OWNEW 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 Owner's or Authorized Agent's Name(Electronic Signature) Dare
NOTTSc.. .. ... .. . .. ... . .. _
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
Information on the Construction Supervisor License can be found at
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"maybe substituted for"Total Project Cost"
CITY OF SaUe8.:..Mb lbLksSAi.d USE A s s
81:IZOm4G D EPA -,,.%nNT
120 WASHNGTON STREET. 3 FL0O&
FAX(978) 7fi,9846
iQi�EFiE_`r.°t DFLISC®1'.�
DIRECTOR OF PUBLIC PROPERTY/Bt UDDLNG COaLMISSIONF.R
(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 c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris /will be transported by: /e
__([.r'(la1 A.! 'd. r`✓ ' ��f �f4
1 (name Ahau er)
The debris will be disposed of in :
141
(name of facility)
�G s /n/
(address of facility
/v
signature of permit applicant
date
debrualt.J.x
CITY OF SMX-.X� XLNSSACH SI~TTS
(� BUILDNNG DEPARTMENT
9 � 120 WASHIN1GTON STREET, Y0]FLOOR
TEL (976) 745-9595
Rim(978) 740-9W
KNY.t13FRy-Fy D&NSCOLL
;l/iAy1OR TI IOBRAS ST.PIE.RRE
DIRECTOR Of PUBLIC PROPERTX/I3t ILDING COMMISSIONER
Workers' Compensation Insurance Affidavit: Iimildelra/ContractorvdElec,ricianslPlmrdToLia
mlieant Information Plese Pri ant E Legim
Nalne(Ousims Orgmizatiowindividuat): �/ 7,/�"+'1/D i/ t J/(J/✓G/
Address: C?" -g �"6,11 407 r 4 C �7 _
City/State/Zip: c xeYt 2�a /s7/r 11,6? Phone H: c/ �� 7 21 G /.7"' _
Are you an employer?Check the apprepriate Neon; Type of prulecli(requlred).
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
mployees(full and/or past-time)., have hired the sub-contractors
2. tam a sale proprietor mr pnrtmer- listed on the attached sheet. 7• ORu'trwdeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑Building addition
INo workers'comp, insurance S. ❑ We arc a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself[Nn wnrkerrc comp. c- 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t crttployces.(No workers' I3.❑Qther
comp.insurance required.]
'Any opplicarn that chocks;box#i most also till out the sccuon below stowing their worker;compensation policy information.
t Ihmmownvs who submit this affidavit indicating they amdoing all wade and then hire outside cnntmetgrg must submit a new afadsavit indismong such.
t'nmrm:turs th,.t check thin hex m w.,fl.hed sheet showing rho aamn of dta flab-eanuogora and(heir worlimm comp,policy mroroauiuu.
lung an employer that is providing workers'eampensudon lasurance jar my employees, lBedorr ds the policy and"site
information.
Insurance Company Name:.
Policy#or Self-ins.Lie.#: __._. Fxpiration Date:
Job Sire Address: -._ City/State/zip: _
Attach a copy of the wor°tern'eompensatiom policy declaration page(showing the policy number and explmtiosi daft).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonmonr,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Se advised that a copy of this statement may be forwarded to the Office of
Invostigatiotu tit the DNA for insurance covcmgo vcrificution.
i flu hereby ter //7/ the patuss ff d penalties of Jary titan fhQ%/Ifarflrarlaa pro Vlf/C 11 above I4'IIYIL'aJPd correct
Siumu Ire: /�f /[i+G'f/7 Outc: �7
Phone 4: S' 7or- �17/
Ofried use unly. Do not write in rhla area,to he completed by city or town nfficial [
City or Town: Pcemse/l.iecnse# t
' Issuing Authority(circle one): _- --� .----
1. Berard of Wealth 2.Building Department 3.Cityrrown Clerk 4.Electrical Nuspectot' 5.Pinmbing Inspector
6.Other
Coutact 1'erwn: _ _ __ ._... Phone#:
1
Office of Consumer Affairs&BJsiness Reaul20oa
HOME IMPROVEMENT CONTRACTOR Type:
Registration 111834
Expiration: 2/4/2013 D8A
KEF
CDONALD CARPENTERIVVOODWORK
s,
KEITH MacDONALD "!
253 CENTRAL ST � �-
GEORGETOWN,MA 01833 'Undersecretary
Ylassilchusetts- Depar-tment of Public S:lfcty
Board of Buildin" Re"'uLltions "d Standards
Construction Supervisor License
One-and Two-Family Dwellings
License: CS 56432
KEITH A MACDONALD
253 CENTRAL ST
GEORGETOWN, MA 01833
Expiration: 81311201 2
(1,nuoisioner Tr#: 229
Afely Insurance BUSINESSOWNERS DECLARATIONS
HOME - BUSINESS
Safety Insurance Company
Policy Number From:%.olicy I Period To
BMA0002706 07/24/2011 07/24/2012
12:01 A.M.Stallard Time at the described location
Transactions
Renewal Declarations
Named Insured and Mailing Address Agent
REITH MACDONALD TARPEY INS GROUP INC
253 CENTRAL ST 442 WATER ST PO BOX 567
GEORGETOWN MA 01833 - WAKEFIELD MA 01880
Telephone: 781-246-2677 33051
Form of Business: INDIVIDUAL Type of Business: CARPENTRY-INTERIOR
DESCRIBED PREMISES
LOC BLDG ADDRESS AUTOMATIC INCREASE
001 253 CENTRAL ST GEORGETOWN MA 01833 4%
PROPERTY77777777
LOC BLDG COVERAGE VALUATION DEDUCTIBLE LIMIT OF
INSURANCE
001 001 Personal Property Replacement Cost $ 500 $ 3, 375
Deductible shown above applies per any one occurrence
BUSINESS INCOME: Actual Loss Sustained Not Exceeding 12 Consecutive Months
LIABILITY AND MEDICAL EXPENSES
Except for Fire Legal Liability, each paid claim for the coverages listed reduces the amount of insurance we provide
during the applicable annual period. Please refer to Paragraph D.4. of the Businessowners Liability Coverage Form.
BUSINESS LIABILITY COVERAGE LIMITS OF INSURANCE
Liability $ 1,000, 000 Per Occurrence
Medical Expenses $ 1o, 000 Per Person
Fire Legal Liability $ too, 000 Any one Fire/Explosion
ADDITIONAL COVERAGES
Some property coverages are subject to deductibles specified in the policy forms.
Optional Property Coverage Description Limits of Insurance
LOC BLDG DESCRIBED COVERAGES
001 001 Contractors Tools - Blanket Basis $ 5, 000
Optional Liability Coverage Description
Limits of Insurance
Contractors-payroll $28, 600
CHANGE IN PREMIUM: $ TOTAL PREMIUM: $ 871
BPDEC2011
INSURED
143"
24" 21" 56" 21" 18"
72 a" 30" 4 a„
36" 18, 3 ' —27"
o W2130L W2130R W183WF3 N N
M
N V o
BWBT18. 24.DISHW BD27.3 BF'
-_...------ - - - - - Cn
m Z N
M in N Q
LO
O � J
M to
00 n
ml�
(D = N O
M M �
OD
rysM
c
-ro p
li O
N
N
-------------------
A 1 101,
All dimensions size designations This is an original design and must Designed:6110/2011
given are subject to verification on not be released or copied unless Printed:6/10/2011
job site and adjustmentto fitjob applicable fee has been paid or job
conditions. order placed.
- -5130F047.KIT All Drawing#: 1