16 GRAFTON ST - BUILDING INSPECTION . GK 23Fsn �f05�'
The Commonwealth of Massachusetts OF
• !� Board of Building Regulations and StandardRECV4 �V1C S CITY
9dYt A )
Massachusetts State Building Code, 1014A,- SALEM
Revised,6/ar 20/1
Building Permit Application To Construct, Repair, Renovate Or tmo h� 0
d One-or Two-Family Dwelling 19,5 Au�
This Section For Official Use Only
Building Permit Number: Date plieeJd:,
V / Building Official(Print Name). '` Signature, Date ,i
SECTION 1:SITE'INFORNIATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
tIs (a n�1„n S'1'
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 ft) Frontage(It)
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 disposalsystem
Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
• 2.1 ,Q wnert of Record:
#*'M1GV C 0LLINl S40 AA 0 )-
i7,hme(Print) City,Slate,ZIP p�.�—GdC�'J
16 �'6w+r Sf- �71, /
No.mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Buildinaw Owner-Occupied1@1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Descn tion of Proposed Work'-:
e� P 4k>�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
-Labor and Materials
I. Building $ I/ YOO I. Building Permit Fee:$ Indicate how fee is determined:
If�. Electrical g �QOO ❑Standard City/Town Application Fee
❑Total Project Cost?(Item 6)x multiplier x_
3. Plumbing S Z,�QQ,� 2. Other Fees:
4. Mechanical (HVAC) S List:. (J
5. Mechanical (Fire $
Su ression) Total r111 Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ J'S'J000 ❑Paid in Full ❑Outstanding Balance Due:
�` 1
oU
SECTION 5: CONSTRUCTION SERVICES,
5.1 Construction Supervisor License(CSL)
L c
' oAe y A 7 fl l�(�(, Licen a ber Expiration Date .
Name of CSL Holder U
6� VV LJ(7 I W"f /� e List CSL Type(see below)
T e Description.
No.and Street . ,
-}f Unrestricted(Buildings u to 35,000 cu. It.)
S(�lae4rt b tO l'/ 1 MA- Q 1 �'J-7 R Restricted 1&2 Family Dwelling
Cityrrown,StJte,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF SolidFuel Burning Appliances
Insl
• ( Q (NA.GI f Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I LlM iJ,
L,4e-(yy Ie— Sev-V1cXJ LLG H[C Registration Number Expiration Date
HIC CeIanY NamemDk v 1, CRegistry t Name 14W
No.and Street W t�'L`r Email addres W 1 7
N+aatyt1trff M/t OIga7 7d'lB� �2J�
Ci /Town,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 horize
-t4 act my If,in al atters five t wo k authorized by this building permit application.
, /J
Print Owner's Name(Electronic SignatureY 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 i this apph ti n is true and accurate to the best of my knowledge and understanding.
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. 142A.Other important information on the HIC Program can be found at
www.mass.goL V Oca Information on the Construction Supervisor License can be found at www.m:us.��oe:'d tLs
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 Cost"
p' The Commonwealth of Massachuselts
Department oflndustrialAccidents
1 Congress Street, Suite 100
Boston,Mi4 02114-2017
www.massgov/dia
Ukrkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leribly
Name(Business✓oiggaant,7Adon/ln4iividual): L..,te—hio J are 2 v 4 CQ j ..
Address: (a / �/V 1n (/lu(/1/ =n /i"_�
City/State/Zip: fa)- rt D D 07 Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
employet with,�R—ensployees(full and/mpan-time).* 7. ❑New construction
2. I am a sole proprietor m partnership and have no employees working forme m 8. odphng
MY capacity.[No workeis'comp.insurance required]
[No workers'3. I am a bomeowner doing all work myself. co - 1 Ong ad
mp.insurance required.]t
4.❑1 am a homeowner and will be hiring connectors toconduct all work on my property. I will 10❑Bnilditig addition.
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plmnbing repairs of additions
5.❑I am a general contractor and I have hired the sub-bomncrma listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insmance.l 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised theirright of exemption par MGL c. 14.❑Other
152,§](4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box#1 must also fillour the section below showing their workers'compeosauon polity infamauon.:
t Homeowners who submit this affidavit indicating they are doing all work and then hive outside contractors must submit a new affidavit indicating such.
lContracaus that check this box must attached an additional sheet showing the name of the sub-com cams and state whether in not those entities have
employees. If the sub-contracems have employees,they must provide their worlm'.comp.policy-.a—.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
Information A EI Insurance Company Name:
Policy#or Self-ins.Lic.M Expiration Date:
Job Site Address: ��Q Cr'VtM�7-'9 fiI t City/State/Zip: W A,+-o )7 70
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 undeo a ins and alties ofperjury that the information provided ve is tr/e and correct
Signature: p. ~/ Date: 2 /
Phone#: O Z 3
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/Idcense#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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."
� 1 t
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 number(s)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 Industrial
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 rust 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
Department 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
CITY OF SALEA MASSAalUSEM
BuiLDm DEPAR7wNr
120 WA%mgGTcNSmmET,31DRom
7kL(978)745-9595.
%IIv>SERLEYDRISQOLL FAX(978)740-9946
MAYOR THORM ST.P EM
DIRECTOR of FmijcPROPERTY/BIDING oomassiomR
Construction Debris Disposal Affidavit
(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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
L. Wlio,le
(name of hauler) I C
The debris will be disposed of in:
(name of facility) _
(addres of acility)
Signatrre 9f applicant
l 2�l i s
Date
t�
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor „
License: CS-095280
ROBERT A PIER
67MONUMENTA
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♦ �� � � Page No of Pages '
.1insured 7�1H� Litehouse Services
' License # 95280 Litehouse Services 67 Monument Avenue
H.I.C. # 142824 Home Repairs Made Easy Swampscott, MA 01907
litehouseservices@gmail.com
s
Bob Pierce 781-864-5238
♦ A
PROPOS SUBMITTEDT;O ^o ((I, PHONE DATE ,✓
STREET �� � /-� G ram+ JOB NAME
i CITY,STATE,;ZIP CODE A f0,��V\ T JOB LOCATION
J�` '`•C^ r iA/PPROX.STARTING DATE JOB PHONE
We hereby submit specifications and estimates for:
Arno e,I Z " 0
CIq b u+
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i
h
errrpnse hereby to famish material an labor—complete in ac or dance with above specifications,for the sum of:
v! . 1 0"' dollars($ I S 000 )
Payment toa Y map as follows:
1/3 down, 1!3 middle of job, 1/3 upon completion
t
II material is guaran[eetl to bees specifietl.All work to be completed in a workmanlike manner Authorized 'M
according to standard practices.Any alteration or deviation from above specifications Involving Signature _ �••/
ertra costs win be executed only upon written orders,and will become an extra charge over and
a have the estimate. -
Note:This proposal may be
withdrawn by us if not accepted within days.
/l
.Ay Letptance of rOpusal—The aboveprices,specifications and conditions are ``�4///
satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment /V.SlgnatUre
aw.-
it be made as outlined above. authorized )
__
Da; ( Signature R
Date off Acceptance: n♦ 7 , �1�
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