11 GALLOWS HILL RD - BUILDING INSPECTION (2) i
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The Commonwealth of Massachusetts
I; � Board of Building Regulations and Standards RECEIVE
j\d( Massachusetts State Building Code, 780 CM��SPECTIONAE ERT NI
Revised,Uar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish A 45
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date:Applied:
ul
Building Official(Print Name). - Signature Date
SECTION I:SITE INFORNIATION
LI Property�.11obwcl'Address:bh 1.2 Assessors Map& Parcel Numbers -
1 I l d I (Z.oQ
„f1 I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(11)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
• SECTION2: PROPERTY OWNERSHIP"
2.l Owners of Record:
na- awot kxda &od2ytz, M A- O iq 7 0
'ame(Print) - City,State,ZIP
Hi</ s
No.mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 13 Ovvner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-:
2e ut2 t0.T CY�C otr t 6fe
1 SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item
Estimated Costs:
Official Use Only
Labor and Materials
1. Building $ 09 1. Building Permit Fee:$ Indicate how fee is determined:
2,300
❑❑Standard City/Town Application Fee
2. Electrical $ -
- Total Project Cost'(Item 6)x multiplier s
3. Plumbing $ 2. Other Fees: S
4.Nfechmtical (HVAC) $ List
5. Mechanical (Fire $
Suppression) Total All Fees:S
OJ Check No. Check Amount: Cash Amount:
. 6. 'Fotal Project Cost /� ✓
V 0 Paid in Full 0 Outstanding Balance Due:
SECTION5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) q l/
�Y&L Pt e V'Ze. License Number Expiration Date •
Name oI`CSL Holder
V�'t7H✓�� � List CSL Type(see below)—a._
No.and Street Type Description
MA 0 M107 Unrestricted(BuildingsFamily
D el ing cu. ft.)
Restricted I&2 F�unil Dwelling
City/ own,State,ZIP M Masonry
RC Roofing Covering
/ I WS Window and Sidin
t�f'+OU e P SE Solid Fuel Burning Appliances
J 3 �'I'✓1(oaf [ Insulation
Telephone Email address fMoA ti ' M D Demolition
5.2 Registered//Home Improvement Contractor(H ) ) 72-p L�'
L_I�Vull�e- tT�t� y�c �G HIC Registration Number Expiration Date
HIC Comyany Name or HIC Regislrt- wvlot,( "wet' /
All
No.and Sue`�a m�,J t0 At M ^ �9� ?br� 4(/J�� Email address
Cit /Town,State, I, IP tt" 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 ........1.1VL1 No...........❑
SECTION 7a:.OWNER AUTHORIZATION TO.BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTORAPPLIESFOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize L 9 uq W o C2J �� •
Mehalf,in all matters . ive work authorized Whis building permit application.
Print Owner s Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED:AGENT DECLARATION
By entering in Hain below, I hereby ttest under the pains and penalties of perjury that all of the information
contained in this licat on is true/ d accurate to the best of my knowledge and understanding.
Bt.{�0�4/ O
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:,
I. 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. I42A.Other important information on the HIC Program can be found at
www.mass.eovoc:l Information on the Construction Supervisor License can be found at evww.mass.,ov'dps
2. When substantial work is planned,provide the information below:
Total Floor area(sq. ft.) (including garage, finished basemealattics,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 Cost" •
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:Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License CS-095280
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' ROBERT A PIER '
67 MONUMENT A
SWAMPSCOTT FAA
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Expiration
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Page No of Pages
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Insured Litehouse Services
License #95280 Litehouse Services 67 Monument Avenue
H.I.C. # 142824 Home Repairs Made Easy Swampscott, MA 01907
litehouseservices@gmaii.com
Bob Pierce 781-864-5238
PROPOSAL SU ITI10. a va v- a 0 PHONE - DATE
STREET JOBNAME
it 2MI IV y 1ad
CITY,STATE ZI C E JOB LOCATION
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APPR X TART GOATS JOB PHONE
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We hereby submit specifications and estimates for:
GPI tQ P.i� �/U (r r►J sc)n p r-
e Propose hereby to furnish material labor—complete in accordance with above specifications,for the sum of:
Payment to be made as follows:
1/3 down, 1/3 middle of job, 113 upon completion
II material is guaranteed to be as specified.All work to be completed in a workmanlike manner Authorized ✓1.��
accoMing to standard practices.Any aberation or deviation from above specifications involving Signature
Na costs An be executed only upon written orders,and will become an extra charge over and
above the estimate.
Note:This proposal may be
withdrawn by us if not accepted within days.
�rreptaxtre of?Proposal—The above prices,speculcations and conditions
ons am 'satisfactory and are hereby accepted.You are authorized to do e work specified.
as spified.Payment Signature
All be made as outlined above.
Signature
Date of Acceptance:
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNUTTING AUTHORITY.
Applicant Information Please Print Leath]
Name(Business/Organizadon/Individual): L-4e_A o ✓J-2 Sey-,4 CC !'
Address: L7 Wont/l'fv- k*
City/State/Zip: t t5Pohone k 7e I �b/
V
Are you an employer?Check the appropriate box: Type of project(required):
1.MI.a employer with employees(full and/or part-time).'
7. New construction
2. I am a sole proprietor or partnership and have no employees working for me m g. ❑Remodeling
MY capacity.[No workers'comp.insurance required]
3.❑loan a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition
4.❑I am a homeowner and will be hying contractors to conduct all work onmy property. I will 10❑Building addition
ensure that all contractors either have workers'compeasation insurance or are sole 1 I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I son a general contractor and I have hired the subcontractors listed on the attached sheet. 13 ❑Roof repaiia
These sub-contractors have employees and have workers'com .p.insmaace.t r
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other ikk✓'iPP— ✓Z/P%f
152,§1(4),and we have no employees.fNo workers'comp.insurance required.] - �
-Any applicant that checks box#]must also fig our the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide then workers'-comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name: X �
Policy#or Self-ins.Lie.#: ti C 00 / /S6 — Expiration Date
Job Site Address: (MU0 -f City/State/Zip:Jrrf Al /tot o tl1 7v
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 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 verification.
I do hereby certify u e the p ins an ena[ties o erjury that the information provided abo is tr a and correctSi afore: Date: 6 / 1 1
Phone M 01�( 3'2 3
Official use only. Do not write in this area,to be completed by city or town officiaL
City 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#:
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of hmdustrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
,Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town),"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Departinent of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia