131 DERBY ST - BPA-16-454 BATH REMODEL U5 G 1 Ty o F a AL6��i
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11ONAL SERV1i;ES
The Commonwealth of Massachusetts , �y�Y
Q Board of Building Regulations and Standar '� 41 -3 I 31A'LEM
Massachusetts State Building Code, 780 C Revised Mar 2011
S Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
l Building Permit Number: Date Appli 9
.� e Q /
Building Oftcial(Print Name) Signature - Date
SECTION I:SITE INFORMATION
1.1 Property Address: ,J 1.2 Assessors Map&Parcel Numbers
;oI/ i)(- L/3 1`7- 6JAirT
Ma Number Parcel Number
l.la Is this an accepted street?yes Jo no
Map
Number
Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Reyuired Provided Required Provided
1.6 Water Supply:(M.O.L c.40.§54) 1.7 Flood Zone Information: I.S sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal Cl On site disposal system ❑
Public❑ Private❑ Check if yes0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner Rre^co '70
12 , i �j6-n /VAFC
Name(Print) City,State,ZIP
/Z/ 7r44y (CAi1TS 6/7- 9Pv a7aS
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Propo ed Work': G e F'
QS )CGOr�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical
❑Total Project Costa(item 6)x multiplier \x
3.Plumbing $ S �]�® ,n� 2. Other Fees:
4.Mechanical (FIVAC) $ List:
5.Mechanical (Fire $ /7f Total All Fees:$
Su ression)
Check No. Check Amount: Cash Amount:_
6.Total Project Cost: $ 71 2C c ❑Paid in Full ❑Outstanding Balance Due:
5(q Ck�t��O 50 "1pH -h4r;WILL� IV .
a SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) {'a_ i L��9 f
.���(Iri 4N0 License Number Expiration Date
Name of CSL Holder
�� List CSL Type(see below)
('J'4 YLI` Type Description
No.and Street
,,,r�t /�' J S. Unrestricted uildin s u to 35,000 cu.ft.
&yLc /04 t..d2 `% � R Restricted 1&2 Family Dwelling
CityRbwn.State.ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
7::
slGKp [o:Im1 Tele hone il address .J- D Demolition
5.2 Registered H//o��m'�'e tractor(HIC) 07 CfzJ01d PE HIC Registration NumberHIC Com Name ar H�/1 .tomd Street mail address
Ci /Town,State,ZIPTele hone
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 Issua ce 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 bSC�I'✓ /�- 7t��'C=i✓ /.i�. T%��' _
to act on my behalf,in all matters relative to work authorized by this building permit application.
int Owner's Name(Electronic Signature) J Azzdg- Date
SECTION 7b:OW14CRWOR AUTHOR GENT D CLARATION
By entering my time below,I hereby attest under the pains and penalties of perjury that all of the information
contained in th' icatio is d accurate to the best of my knowledge and understanding.
S— I ZO/6
Print Owner's or Authorized I s e(ElectronicSignature) 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 nims.eowoca Information on the Construction Supervisor License can be found at w�vwanass.uov/dus
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 Cosf'
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.govIelia
vw���Grkcrs'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.TO BE TILED WITH THE PERMITTING AUTHORITY,
Applicant Information Please
J Please Print Legibly
Nance (Business/OrganizatimtAndividutd): ke, )tA S/1we of eu
Address: a?11 padIt ae
City/State/Zip: Aevexe 4 4Z(S/ Phone 617-593.9215—
Are you an employer?Check the appropriate box: Type of project(required):
I.R I at,a employer with?�Y employees(till and/ar part-tine)° 7, New construction
2.E]I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.INn workers'comp.insurance required.)
9. El Demolition
3.❑I am it homeowner doing all t%mk myself INo warkers'comp.insurance required.]r
10 Q Building addition
4.F-�I an a homeowner and will be hiring contractors to conduct all work on my property. I will
ensuro that all conV2etors either have workers'compensation insurance or are sole 11. Electrical repairs or additions
propdctmswid,nn cmployees. 12.❑Plumbing repairs or additions
5,R 1 an a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-conlmclors have employees and have workers'comp.insuratim:
14.EDOther
6.r�We are o corporation and its officers have exercised(heir right of exemption pm MGL c.
152,c 1(4),and we have no employees.[No warkers'c unp.insurance required.]
*Any applicant that checks[tax gl must also fill out the section belor:showing their workers'compensation policy inf nnattoo.
r Hatneuwners who submit this afrrdn.h indicating they are doing ill work and then hire outside contractors must submit a new affidavit indicating such.
tComractors dial check this box must attached an additional sheet showing the mane orthe sub-contractors and state whether or not these entities have
employees. If do sub-contractors have employees,they must provide their workers'comp.policy number.
I out all employer that is providing workers'compensation insurance for my employees. Below is the policy and job.site
information.Insurance Company Name: yYtrA�Sn T.5 HyttAl 1 e e.rfG
Policy#or Self-ins.Lie.#: W C�100/0 3V ( Expiration Date: {/4
Job Site Address: 1 flgg to ST Uh'T { � City/State/Zip: f�[v��
Attach it copy of the workers'comperlsation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL e. 152,§25A is a criminal violation punishable by a fine up 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage vertncati
TPhone
reby certi under due ruin. r penalties o/peijury that the inf l-ruatior provided bovee//.s true and correct.
ure !/+�(/Z Date- e? n t2
F
icial use only. Do not write in this area,to be completed by city or townofficial.
y or Town- Permit/License#
Issuing.Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person; Phone#:
9LOZ/OL/LO
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Office of Consu�Affairs�andBusiness Regulation
10 Park Plaza� Suite 5170
Boston, Massa kjusetts 02116
Home Improvement Contractor Registration
Registration: 137430
Type Private Corporation
Expiration. 11/1,2/2016 Tr# 258489
NORTH SHORE DESIGN INC.
JOSEPH FRUCIANO -
211 PARK AVE. -- —/--- ---- -.
REVERE, QUA 02151
V,-0 __—
,yUpdate Address and return card.Mark reason for change.
scni C. zom-osm � - L,I Address Renewal 4jl Employment [-i Lost Card
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All dimensions size designations This is an original design and must Designed: 4/30/2016
_ given are subject to verification on not be released or copied unless Printed: 4/30/2016
job site and adjustment to Fit job ^ applicable fee has been paid or jab
conditions. 2 2 order placed.
Bathroom 11 JAII Drawing 4: 1 No Scale.
Boston
-"--__Mitt en Safes Agreement
Designs
215 South Main Street Sales order# 7723
Middleton, MA 01949 Jobrrag# FITZPATRIC-GN
Phone 978-750-1403 Date 4/30/2016
Fax 978-642-9595
Bill To Ship To
PAUL CHARLOTTE FITZPATRIC PAUL CHARLOTTE FITZPATRIC
131 DERBY STREET#5 131 DERBY STREET#5
SALEM MA 01970 SALEM MA 01970
CHARLOTTE 617.980.2725 CHARLOTTE 617.980.2725
PAUL 617.480.7120 PAUL 617.480.7120
Designer GM-0 Store Loc Terms
Ln.# oty. Item Wr. Model&Description Rate Amount
Cabinet ULTRACRAFT DOOR STYLE SLAB WOOD BAMBOO STAIN 6,172.00 6,172.00T
AMBER
Tile FITZ TILE MARMOL COLLECTION COLOR CAFE 3,885.00 3,885.00T
,BATH FLOOR 12X24 MATE WALL TILE
12X24 GLOSS SHOWER FLOOR 2X2 MATE.
GROUT TO MATCH TILE
Countertop PENTA QUARTZ FOR VANITY TOP,TUB DECK,THRUST 3,895.00 3,895.00T
HOLD AND NICH IN THE SHOWER ONLY IF
REMNANTS ARE AVAILABLE OTHER WISE
WILL CHANGE COLOR ,WITH SQUARE
UNDERMOUNT SINKS
Installation CONSTRUCTION AS PER AGREEMENT 55,631.00 55,631.00
Delivery DELIVERY OF PRODUCTS 580.00 580.00
PAYMENTTERMS
DEPOSIT$20,000
2 DAYS AFTER THE JOB START$15,000
ON ROUGH INSPECTIONS$15,000
ON TILE INSTALLATION$15,000
ON SHOWER DOOR INSTALLATION$5000
ON COMPLETION$1,035
i
We Appreciate Your Business! Subtotal $70,163.00
Sales Tax(6.25... $872.00
www.hostonkitchen.com Total $71,035.00