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1 FLYNN ST - BUILDING INSPECTION � . , �3- I �-( - "7 ZZ- ��� � l � ��c ( g � s �' � z��' � fhe Commonwealth oF M�ssachusetts CfI Y OF +� DoarJ of[3uilding Regulations anJ Standards SALE��I n ��,� iblassachusetts Stare Building Cude, 730 CMR Revieed.11ur?0ll Building Permit Application To ConsUuct, Repair, Renovate Or Demolish a One-nr Tiva-Fa�nily Divrllin,q This Section For OFficial Use Onl Uuilding Permit Number. Dnte Applied: • � Si e 3 u'"u l)uilding 01'tici�t(Pnnt Nume) � � - SECTIO� L•SITE INFOR��IATIO�F I.� Property AdJress: LZ Assessor�i�inp.g P�rcel Ymnben � h �4 S+ I.i a ls thi,nn�ecepted street?yes no_ M1�up Number Purcel Number 1.3 'Loning Intormntion: I.J Property Dimensions: ( � Lut Arca s tt Frontuge Qt) � Zuning Distric� I ruposed Usa � 9 � a I.5 �uildingSetbncks(R) Frant Y:vd Sida Yanls Rear Ynnl Reyuircd ProvideJ Reyuired Provided Rcquired Provided 1.61Vnter Supply:(M.G.L c.d0,§Sd) 1.7 Flaod Zone Informatlon: LS Sewnge Disposnl System: Zune: _ Ou�side Fluod Zone7 Municipnl O On site Jispos�l syslem ❑ Public❑ Private❑ Check if esO SECTION2: PROPERTYOWNERSHIP�' 1.1 Owner of Rewrd: � �k �� �} � �y �J �hn�Im � nen rint) Ciry,Slute.ZIP � �F�� �+ �sz6 Nu.mid Slrect Telephona Emuil Address SECTfON J: DESCRIPTION OF PROPOSED 1VORK3(check nll thnt npply) Ne�v Construction❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alterntion(s) ❑ Addition ❑ -emolitiun ❑ Acczssory Bidg.❑ Number of Units Other ❑ Specify: riaf cription of Proposed 1Vurk': � .e ' �' I � N ► � � o , W �' .p SECT(ON 1: ESTIMATED CONSTRUCTIOV COST3 v Estimated Custs: Ofticial Use Only � «°� 6 L:�bur anJ 6laterials) Ilui i; � ��-�� I, E3uilding Permit Fee:S Indicate how fce is determined: ❑Stlndard City/Tuwn Applicatiun Fea L'leu`�nl � p Total Project Cost�(Item 6)s multiplier x 1. Plwnbing .'S ?. OtherFez9: .T 1.�Itthanic:d (HV;\C) J Lisk 5. :\f�ch;inie:�l (Pirc � CulalAllPces:3 tiu ressiun) i CheckYo. CheckAnwunt: Cash:lmuunt:_ i C,. Tuf:�i Projcct Cust: S ❑Paid in Pull ❑Outstanding tlalance Duc: �H/L � /TG/'y!� UcN'�/� ��� 3 � �'1 SECTIOV i: COiVS'CtiUCf[ON SF:RVICES I � 5.1 Cunstruction Supci�fsor Licciue(CSL) �� ��� ) / /,r ���1— ���/ � L� y Licc�uc Numbcr Expimtiun Dure �.� � Nnmc o(CSL HulJcr Lisl CSL'f ype(see buluw) � �"7 �`^` �'-S- C``'E= �I Type . . � Descriplion Na and Strecc / � O'�36 U Unrc�victed [luilJin su Io35,000cu. lt. : �j..�-},{7l � /-/ R RcsVicteJ 13c2 Funil U�vellin � Citylfuwn,5tute.ZIP M �Lison I RC Roolin Cuvcrin WS 1Vinduw;u�dSidino SF Sulid Fuel Duming r\ppli;uiccs ' p OZ3,� I (nsulation 7'cl� hone Email address U Demaiitiun 5.2 Rcgistered t[ome(mprovement Contractor(HIC) ��4 a-� � �^'L� � S�on 1 /G..n._1.o/ / c HIC Registr�liun Number G.epirutiun U:ite . f IIC Cump:uty N:�ne u—�Regislmnt N;une , � � � j ��-�- .c� � �G � � Nn. and Strce�� � N/� �,�� y�Z� Cmuil aJdress Cit /'Po�vn,State ZIP Tcle hune SECTION 6:WORKERS'COMPENSAT[ON INSURAYCE AFF[DAVIT(bLG,L.c.152.§ 25C(�),. Wurkers Compensation Insurance affidavit must be compieted and submitted with this applicatioa Failure to provide this nFtidavit�vill result in the denial of the Is§uance of the building permit. Signed AFfidavit Attached? Yes ..........❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WF1EN: i' O�YNER'S AGENT OR COIVTRACTOR APPLIE9 FOR OUILDING PERMIT I,as Owner of the subject property,hereby authorize - t9 5ct an my behaif,in all matters relative to wark authorized by this building permit application. ��1S1LL�������—, 7/ 6 /Y Prin[Owner'y Nm e(Electronic SiE;nawre) �� I SECTIO�7ti:OWNEK�OR AUTFIORIZED AGENT DEC[.ARA'CION Dy enterin�my name 6elow, I herebp attest under the pains vid penalties of pery'ury that all of the informntion � cuntained in lhis upplication is true and nccurate ro the best oFmy knowledge and understanding. .� �! ' � 1'rint O�vncr's ur Autharizcd Agcnl's Nunm(E'Icctrunic Signature) Dntu ' + NOTES: , I. An Owner who ubtains a builJin�pennit to do his/her o�vn work,or an ownet�vho hires an unregistered contractor ; � (not registered in Aie Home Improvement CunVxtar(HfC) Program),will iiof have access to the arbitmtion a prugr�m or�uaranty Fund under�I.G.L.c. 142A.Other iinportant inFormation on the FIIC Program can be found at . { '' �e�vw.mass.��ae:'oc;i Inform��iun un the Cunstructiun Supervisur Lianse c:m be Found�t�ow��.in;us.eo�:'dL}s � � �. 1Vhen substantial�rurk is planneJ,provide tlta inFormation below: �^ fotal fluur area(sq. f1J (including gua;e, tinished basement/�ttics,decks or purcli) j� Gross living area(sq. ttJ Nnbitable room count I Num6croF tireplaces Vumber oF beJrooms Numhcr ul b;uhrounu Vwnber uFhalf/baths 1'ypc ul'heating syitem Number uf Jeck�/purches l'ypc uFcuuling syitcm f_uduicd Opcn_ 1 "I�und Projaet Syuare Fuue�ge"m:iy be;ubstituted firt"fucd Prnjact C�i�t" � I CITY OF S,�1L M, 2NINSSACHL'SETTS BUILDING DEPARTNI&\T ^�sYi r 120 WASHINGTON STREET, 3'a FLOOR `tea TEL (978) 745-9595 Rax(978) 740-9846 KI.\[BERL F.Y DRISCOLL THONLASST.PIERRE V4.3YOlt DIRECTOR OF PUBLIC PROPERTY/BC[IDL1G CO\LMISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information //�� Please Print Legibly Name(Business,Organ izatiorvi ri ividual): 740 WC it 4 d wf Address: 07 A�_ ,�, Zf,,L TCL 4 City/State/Zip: 0101 6 Phone if: 9?y 'For C z 3J- :1 re y an employer?Check the appropriate box: Type of project(required): 4. 0 1 am a general contractor and 1 \ I. I am a employer with � 6' 6.' [-]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I cora a sole proprietor or partnr:r- listed on the attached sheet.; 7. E] Remodeling ,hip and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. Building addition [No workers*comp, insurance 5. 0 We are a corporation mid its required.) officers have exercised their M0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions myself.(No workers'cunap. C. 152, S 1(a),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.0 Other camp. insurance required.) •Any opplicani nut checks bus sl most also fill out the soctiun 6olow showing their wotkers'compensation policy inlbrrnatiun: 'I4.mcowtw•n who suhmll this affidavit indicating thcy arc doing all work and then hire outside contractors most suhmit a new affidavit indicating such. $',mtnctuts thus check this box coma anach d an additii,nal sheen showing the nwne of the suba ntnetors and Ihcir workers'comp.policy information. I am an employer that is providing workers'contpeusadon brsura cejor my employees. Below Is rhe polky and fab site iafanuation. Insurance Company Name: Policy H or Self-ins. Lia N: Expiration Date: Job Site Address: / of 1. City/Slate/Zip: ,—ceto , M/a— ,kttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51,500:00 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 coverage verification. I do hereby c errii rut a pains d pemuldes of,veryary that the infuirnation provided above is true and correct S •mitt Uotu: 14 Official use only. no not write in this area,(o be conspleted by city or lown official Cityor'fuwn: Issuing,itulhority (circle one): 1. Board of llcalth 2. Building Department 3.C.'itylruwn Clerk a. Electrical inspector 5. Plumbing Inspector G.Other ..---- Contact Person:_ _. Phone -- CITY OF S,1LE\,f, ;tiLXSSACHUSETTS 3 / ©1:tIDL\G DEPARTNONT 120 WASHLYGTON STREET, 3`FLOOR TEL (978) 745-9595 FAA(978) 7.10-9845 KEN tHEltLcY DttlSCOLL &L-kyoa T1ioxw sT.PIERRB DIRECTOa OF puaLIC PROPERTY/SUILDCYG COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In uecerdance with the sixth edition of the State Building Code, 730 CMR section l t 1.5 Debris, and tie provisions of NIGL c 40, 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 disposal facility as defined by rNIGL c I 11, S 150A. The debris will be transported by: ti (name of hauler) The debris will be disposed of in ; to 1v (narne of facility) -- _---(address of titcility) si vure ofpermit applicmt aw Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-086200 ' `;-Fa is HN E HOWELL:` 07 HAERN H LM STER NH 03036 Expiration Commissioner 08/02/2015 �»� raoanmzonu�rall/c o�U�u¢�ac%rmelC_a. Officeof Consumer Affairs&.Business Regulanou.w ME IMPROVEMENTCONTRACTOR'_. 3 ' egistration 1163407 .--, -TYPe , xpiration -Sh1�6/20�� DBA s HOWELL AND SONS REMODELING'(- ' JOHN HOWELL _, i 107 HARANTIS LAKE RD, CHESTER,NH 03036 "r` Uodersecreta ry.