61 COLUMBUS AVE - BUILDING INSPECTION (2) . �
�, The Commonwealth of Massachusetts
°�y Boazd of BuIlding Regulations and Standazds Si��
� �j Massachusetts State Building Code,780 CMR Rwised Mar 2011
Building Permit Application To Construct,Repair,Renovate Qr Demolish a
� One-or Two-Family Dwelling
��� 7'his Section For Official Use Only
� BuildingPetmitNumber: D Applied:
� ��).
�°� � ��
� Building Official(Print Name) Signature Date
SECTION l:SITE INFORMATTON
1.1 operty Address: 1.2 Assessors Map&Parcel Numbers
? 1 Coc.����t�s AJ �z
11a Is this an accepted street?yes '�_ no Map Number Parcel Number
IJ Zonfag Informallon: lA Property Dimeneions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(k)
� Front Yard Side Yards Reaz Yard
Requ'ved Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 19 Flaod Zone Informatlon: 1.8 Sewage Disposal System:
Public� Private❑ Z°°e: _ Outside Flood Zone? Municipa�On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner�of Record•
� ��u ; ,�-e �a w (� S� l.� h-t /l.( /-�- 0 /9 7b
�%`P"n� o l� h�rs ��� �,ry,s��,Z,P
`/�" �f��t�'+ C�v/�
No.aod Street � Tel�one ���/ Email Address �yf� S� .�'e�
SECTION 3:DESCRiPTION�F PROPOSED WORK=(check al�that apply)
New Constcuction� Existiug Buildin Owneo-Occupied . Repairs(s) Alteration(s) Addifion 0
Demoli6on Accessory Bldg.� Number of Units�_ Other ❑ Specity:
Brief Description of Proposed Worl�: I ' �. �t�/ !�i�i L P � PL aJ �
SECTION 4:ESTIMATED CONSTRUCTION COSTS
I� Estimated Costs: Official Use Oniy
bor and Materials
1.Building $� !`�'�' 1. Building Peimit Fee:$ Indicate how fee is detennined:
2.Electrical $ ❑Standazd Ciry/fown Application Fee
d�' ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ y0 —" 2. Other Fees: $ � �/��'��(
4.Mechanical (HVAC) $ �"'p�j'� List: '\f..�. � �
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Casfi Amount:
6.Total Project Cost: $ 3 f 31 S � ❑Paid in Full ❑Outstanding Balance Due:
K��d� �ai�►�.
, SECTION 5: CONSTRUCTION SERVICES
5.1 Coostrucdon Supervisor License(CSL) ��� ��„ ,�
^ � I / y'�5
�T'�'E!�" ��✓ License Num er Exp�ration Date
Name of CSL Holder n �
�� n ��^ r� \ �.` List CSL Type(see below)
�`�C�� wv J
No.and Sheet ,,A Type Description
JCW�`2(�'�/(sh GC 16`� u u�5m�ua sU��au, s u �o ss,000�U.s.
� R Restrictedl&2Famil Dweliin
City/fown,Sta[e,ZIP M Maso
RC Roofin Coverin
WS WindowandSidin �
SF Solid Fuel Btvning Appliances �
�. `3l Oor6 `"G.'7'V.lY�F�a-�Ca�`.�y'7,!'`��� I InsWation
Tel hone Email addreas D Demoli6on
5.2 Registered Home Improvement Contractor(ffiC)
7- 1y�y � / ��.��lv _�����J
�� �&�v ��"' HIC Re�stration Number �F�cpuation Date
HIC Com any Name or HIC Regis[rant Name P�-. (,
r, ��1�6VFkZ^�U�"ef��7.e'�'�G
No. ` et ' Email address
L- 3 f dvcb
� own Sfate,ZIP 7� Tel hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(�)
Workers Compensation Insivance affidavit must be completed and submitted with this application. Failute to provide
this affidavit will result in the drnial of the Issuance of the building pertni[.
Signed Affidavit Attached? Yes..........(� No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUII,DING PERMIT
�' � �
I,as Owner of the subject property,6ereby authorize �.T �A r..i n�
to act on my behalf,in all matters relative to work authorized by this building pertnit applicafion.
' ' ' ' I !/
' t O�mer's Name(Electronic Signeture) Date li
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 flvs application is true and accurate[o the best of my Imowledge and understanding. i
�-c�c �i�,�/aY'�l �� � "' :S ��
Print Owner s or Authorized Ag Nsrn�' ame(Electronic Signature) � Date ��,
NOTES:
I. An Owner who obtains a building pertnit to do his/her own work,or an owner who hires an unregistered contractor
: (not registered in the Home Improvement Contractor(HIC)Pro�am),will not have access to the azbitra[ion
prograzn or guaranty fund under M.G.L.a 142A.Other imporfant inFormation on the HIC Program can be found at
www.mass.eov/oca Infotmafion on the Constructian Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor azea(sq.ftJ (including garage,finisheA basementlattics,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/potches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be subs6tuted for"Total Roject CosP'
� CITY OF S.�LE.�I, �I.-1SS.-1CHL'SETTS
�• ' BL'II.DL�iG DHP�RII�.V'T I
' 130 WASHL�iGTON STREET,3'D F7.00R '
�` TEt_ (97� 7;5-9595 I
FA.r(97� 740-9846
KiJIBERL.EY DRISCOLL
LUYOR 11i0ANS ST.P[ERRS
DIRECTOR OF PI;HLIC PROPER'IY/H[;IIDII•iG CO�L\([SSIO�iER
Construction Debris Disposal Affidavit �
(required for all demolidon and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 11 I.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resuldng&om
this work shall be disposcd of in a properly licensed waste disposal facility as defined by MGL c
l 11, S i 50A.
The debris wiil be transported by:
�i(L�.�FM,A-S7�t,2� f,U�/' �
(name of hauler)
The debris wil] be disposed of in :
j�i�-uS
(name of facility)
��`�� �� � ' ��� �
(address of faci ity)
�� ����
signature oFpermit applicant
��
� - 5 �
date
JcbriutLJ�x
i CITY OF S.�1LE:�I, l�'L�SS.�CHLSETTS
• • BtiII.DL�iGDEPARII�YT
` 1?O W�SHL*iGTON STREET,Y°FLOOR -
�� "I�L (97�745-9595
FAx(978)740-9846
tU�tBERI.EY DRISCOLL
ibL�YOR �I�toMAs St.PiF�txB
DIRECTOR OF PL:HLIC PIIOPERTY/BL'II.DCVG CO�L�aSSIOVER
Workers' Compensation Insurance Aflidavit: DuilderslContractors/EleMrtcisns/Plumbers
A Iicant Intormation PI ase Print Le i I
Vame�e�s�ne�or�cmuomi��u��aw�1: i �Cs� �o�. 1
/
Address: � �� � 1'
City/State/Zip:�G�(�CG'7/�"!4 vt�'ro7 Phone N: 7�'� �la �� �O(,�
Arc you rn employer?Check fhe appropriate 6os:
I.�am a cmploya wirh�_ 4. 0 t am a gencral conhacar and 1 TY�of project(required):
employees(full and/or part-cime).• have hired the subcontracmrs
6. ❑New convwction
2.0 1 am a sole proprietor or pertncr- listed on the attached sheeG: �•�Remodeling
ahip and have no employecc These sub-conhacWrs heve 8. �Demolition
working for mc in any capacity. workera'comp,inaurenee, g, �Buitding addiaon
(No workers'comp.insurance 5. Q We src a cofporation and irs
rcquireJ.] officas have ezercised theu ��•0 E��n���repairs or additions
�3.� 1 am a homcrowner doing all work right of exemption per MGL 1 I.Q Plumbing rcpaira or additioua
myself.(ho workers'comp. c. 152,�1(4),and we have no �z,�Roof�epai:s
insurence required.j t cmployeea.(No warkers' I3.0 Othu
comp,insurance requ'vcd.j �
•Any yryGp'M1 Iluu dLLxita hox NI muel aLw fill uut Ihc�eclion below showiog thnir vptkpa'cumpenwion�pliry infumiaUon.
T IL�m:ownen who�ubmit Mis o%idrvit iiWioting�hey ae doing all wmk�np�hco hi�e owide wnt�cpn muft abmit a naw alfiJavil i�dialiug weh �
�('on�a.�ton�ho�chrck i6is box m�nt anxhod an mWi�iwml uha�dwwuip tic nomc of tln eubcontncton aiW thc4 workrn'comp.poliry infa'murim. �
/um va amployer rhet ir prevlding worke�a'rompensadon lnruranee jor my edrployeer. Betow Ia rhe polfcy andJob stle
injormmion. i
In�urrnce Company Vame:_ _ �i.�R'� �L i�, S�A-!� ( /J,S ��5
Policy q or Sclf-ins.Lia H: � L b � � S= 1�-1 z �
/ � Expiration Dute: �
!ob Sire Addross: b � C'�L ('�(� S ;�(/ � CirylSmte/Zip:r�� /'-��' �� 4 7b
,\ttach a copy of the worken'compensadoo pollty declnrattan page(showing t6e polley uumbar aad e:pinNoe date�
F�ilure w s�;ucc covewge as required unJer Scetion 25A of MGL c. 132 can lead ro the imposition of criminal penaltiea of a
fine up to S I,S00.00 and/or one-year imprisonment,us well as civil penaltins in t6e form of e STOP WORK ORDER end s fine
of up ro 5230.00 a day abainst the viotator. 13e advised that a copy uf ihis�tatcm�rot may b�:forw:uded to�he O�ce of
Invcs�i�iiunx uP thc DIA for insurance covorage v�:rification.
/do he�eby cm jy uwder nc�patns m�d pena/t!u ojpe�jury diat f!u&ijormuBon providrd ubove Is lrue und correcR
.�., �"`--�L_ ��o� /- S—l�
��. �� �����G
OJJ7cia!ux only. Do not write in rhls arca,to be cumplNed by ciry or rowa ojJkird
City or Tuwo: PermiUl.Icco9e#
Issulag Aulhority(circle one):
1.13uard uf Ilevlth 2.Ruildin`Department �.Cityll'own Clerk 4.Electrteal[nspector 5.Plumbing Inspectar
6.Olher
Conlact Pcrwm Phaae p:
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RhhIC�E Wfci.L SINK wALL
� -A L L D t M E N'S 1 O N S A.N D p DESIGN PLqNS ARE PROVIDED FOR.THE FAIR� DESIGNED FOR gy DATE BY - SCALE DWG
DWN 40 1�-11� lJ=� „ � � NO.
' SIZE DESI-GNATIONS, � �� USE BY TNE CLIENT OR HIS AGENT IN� CRW I-E�I RESI'�ENG� REV �z = 1,- .
�GNEN ARE SUBJECT TO COMPLEf1NG THE PROJECT AS LIS7EU WRHM�� � �
VERIPICATI'ON ON JU�B THIS CONTRACt DESIGN PLANS REMAINTHE � - � ' i1 �
� �SITE AND ADJUSTMENT TQ. - � PROPERTY OF THIS FIRM AND �CAN-NOT BE - "
�fIT.JOB CONDITIONS.` ;� Nffiional Kitchen&Bath Association USED OR REUSED WITHUUT PERMISSION. � .
N154258-8002 .., . . . .; . .
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CERTIFICATE OF INSURANCE 06I1612011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE
CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED
BY THE POLICIES BELOW. THIS CERTIF�CATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN
THE ISSUING INSURER S , AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION
IS WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement
n this certificate does not confer ri hts to the certificate holder in lieu of such endorsement.
PRODUCER
Thomas Gregory Associates Ins Agcy Inc
601 Edgewater Dr, Ste 235
Wakefield, MA 01880
COMPANIES AFFORDING INSURANCE
COMPANY A GRANITE STATE INSURANCE COMPANY
INSURED
Dow Ethan
DBA Ethan Dow General Contracting
95 Rockland St
Swampscott, MA 01907
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR
� l"HE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER
DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE
POIIGES DESCRIBED HEREIN IS SUBJECT TO ALL TNE TERMS, EXCLUSIONS AND.CONDITIONS OF SUCH POUCIES, LIMITS SHOWN
MAY HAVE BEEN REDUCED BY PAID CLAIMS. . .
co
LTR TYPE OF INSURANCE POLICV NUMBEft POLICY EFFECTIVE DATE POLICV E%PIRATION OATE
P, ORKEftS COMPFNSATION -
ND EMPLOVERS'LIABILITV LIMITS
HE PROPRIETOR/
� � PARTNERSIEXECUTIVE
FPICERS ARE
iNc�o exc�❑ 6484192 5/18/2011 5l18/2012 sTnruroRr umirs _
. —1�iiek - --- -- �
Coverege Appiies to MA Oparalions Only.
� ACHHCCIDENT $ IOO,OO
� OISEPSF POIICY LIMIT $ SOO,OOO
�� _ OISEASE-EACFI FMPLOYEE_ $ 1 OO,OOO
�DESCRIPTION OF OPERATIONSNEHICLESlSPECIAL ITEMS
E: THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVEF2AGE FOR DOW ETHAN.
� • —
CERTIFICATE HOLDER CANCELLATION
�. � SHOUL�ANV OF'I'HE ABOVE DESCRI�EO POUqES BE CANCELlEO BEPORE THE
' E%PIRATION DATE THERGOF,NOTICE WILL BE DELIVEREO IN ACCORUANCE
- R WIHTE THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE �
/f� /
�-�._� ' �_Py-s�_..r
� . .'.j,c�"✓�..:,, _.. �
CJ ,.
, � Massachusctts- Dcpartmcnt of Public Safch�
� Board of Buildin� Rcgul:uions and Stand:�rds
� Construction Supervisor License
� License: CS 66844 � � '
, t
ETHAN E DOW � , �
95 ROCKLAND ST
SWAMPSCOTT, MA 01907 '� .
o—
�'�" 'y�`� Expiration: 5/29Y2073
('ounnisgiuner ' Tf#: 77544 � I
. /��¢.� '4, 4 5����V�#��W Tt;�� .
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�`�, DRIY�RSLICENSE'�" '
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��SWANFSCOlT,MA . '§�' � f y���,rr'" . �
0190�2523 . .. � M,a� 'e�ti"�+�",'"�.�y�,'� �� �
� Office�f�o�mer al�irs&�Bu£ioessRegulaho�o .
_� HOMEIMPROVEMENTCONTRACTOR '
Registration: ��32456 � Type: -
.� Expiration: .ti8/20,13 DBA '�� .
�' ==r=��==� . �
� E � DOW GENEftAL_CONTRACTING -
— ����i
ETHAN. DOW- '�� - c= 1; �
- 95 ROCKLAND ST.f, '��--��"
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- SWAMPSCOTT, MAC0�,907 fy Uodersec�etar� �
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