7 GRANITE ST - BUILDING INSPECTION (2) --- I'lie C'onunontvcalth of INl:usachusctts
y Board of Building Regulations and Standards CI I'1'OF
1p Massachusetts State Building Cute, 780 C'NIR SALI:.\I
Building Permit Application To C•onslruct. Repair. Renovate Or Demolish a
Une-or ris o-Furrnll Dii o in,p
This Section Fur 011iciul Use Onl
Building Permit Number: _ Date Appli — —
7l
Ela
Jiny Oliicial(Print N�une) Sigrtaturc Dale
SECTION I:SITE INFORMATION
opert Address: 1.2 Assessors MAp Ji Parcel Numbers
this an acce ted street? es no Map Number Purcel Number
LIJ Zoning Information: 1.4 Property Dimensions:
L,ning District I'ropuseJ llac Lill Area IN It) Frontage(II)
I.t Building Setbacks(It)
From Yurd Side Yards Roar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. Jo, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑� Prit ate❑ Zone: _ Uubide Flood Zone? Municipal O On site disposal s vlem O
Check IY ivs0 P Po )
SECTION2. PROPERTY OWNERSHIP'
2.1 Owner'of Record:
F(z�V A ry\,am S rXI Cx� m� l L
Nmito(Print) I.Ity.btatu.LIP
Nu.and Street roephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKs(check all that apply)
New Construction❑ 1 Existing Building O Osvner•Occup(ed ❑ Repairs(s) Alterations) Addition ❑
Demolition ❑ Accessory Bldg.❑ Numberof Units Other ❑ Specily:
Brief Description of Proposed Work':
SECTION a: ESTI,M ATED CONSTRUCTION COSTS
heal Estimated Costs:
I labor mtd .\Lterlaisl Official Use Only
I. Building S U I. Building Permit Fee: S Indicate huw fee is determined:
2. Electrical S ❑Standard CitpTu%�n Application Fee
U ❑Total Project Cost'(bent 6)x multiplier _ _ x
2
t I'hunhing S _ _ .._• ._
O _. Usher Fees: S_
J. \1"Itmlic,ll ill\ \(l S List:
< \Icchanic.Il it -_
�t y rcisionl S rood it Fees: S_ -
n I'ulal Project Cos: j (hrd Vu. _. _._( ht'ek AIINnIIl: , _ . ,l',nh \moumt:
❑P 6d in Full 0 Outstanding 11.ILmce Due:
St:('1'll)NIt ('ONSI'RII(TIONSER\'1('FS
5.1 ('unstruc'timl Supcnisur Liccuse I('SI.) -��( „- /
I Iccnse Nunlhcr I splr:umu bate
I III CSI. 1)Ile l.acbcluttl,._.rt
-I- ..._..4 -�.7—`.'rr r-" -. — I',pe Iki:riplinn
N. mJstrcal tl I hlrestriocJ l limn in's tio al 14.000,11. ILI
11e,trtoeJ IR] I.unil Dmcllin
� Nl.isonry
Ci )i loin, Slane./II' v
I(L' Nntdin Cos erin
µ'S µ'11100W.mJ Win
SF Solid Fuel I)urning Appliances
D tZ_QI 1_-�-{ f nwil address D Dcnwliliun
1'elc hone
6.2 R I red flume Improve,,m�e�nt1 Cuntnwor IHIC) IIICItc
gistr; iun Number Ifspirutiun Dale
I IIC l tpnpwl Imc ur I IIC Iteglslrurµ,[1+�a
V QI� nn� tJ�,n �I ']�11 I.mail aJJnss
Nu.an , V P JC�7P 1X '�'7 d'7 ��y`n
Ci Down. State ZIP 'rife one
SECTION fit WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS]. I ]3CM)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuano of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7s:OWNER AUTHORIZATION TO WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as owner of the subject property,hereby authorize
to act ol" behalf,in all matte relative to work authorized by this building permit application.
y � ZZ-
Date
I'rinl satcr's Nwtle(Licclrunw Signaluml)
SECTION 7b: OWNERI 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 this application is true and accurate to the best of my knowledge and understanding.
I' 'nt Qtuwr's ar:\ulhunreJ,\emu s N,una Il.lulnnuv Slgnawnl
NOTES:
7liensubs
er svho obtains a building permit to do his her utvn Mork,or an owner svho hires an unregistered cuntr%lor
stered in the Hume Improvement Contractor IHIC) Program).svill rrr have access to the arbitration
or guaranty fund under\I,G.L. e. I12.>.Other impurant information on the HIC Program can be found at
�. '��t I Information un the Construction Supervisor License can be found at rr tt" Ilea`• '�'1 'ill`
bsl:tntial twrk is plamled, proside the fill orinclludiion n'I�ta'c, finished basementattics.Jerks or porclu
ea i;y. 1l.l . _---"— b garage,
)lubitable room count . -. ... .
- Groislisingareaisy. 11.t .... .... -_. . \timberothedrunns
I
' \umberul Iircploces _ --- \unlher III'hallhathi i
\umberathahrconts
I,Npe lit'hc.tings).lem GunhcrldJccks por.hcs
I\pe of Cooln+Q l.tellt I IIC IP.dJ . .l tl+dll
1 i oi,Ii Protc.t Square 1:001.1ce , n+a� Iw `uhsutulcJ t11r"I1 tal I'roj"l Cost"
CI'CY OF S.�LE,� I, NWSACHUSETTS
BUILDING DEP.\ATMENT
• ' 120 l A31-INGTON STIEET, 31O FLOOR
�_`•o/� ' TEL (978) 745-9595
FAX(979) 710-9944
,:1.NIpE,UEY DRISCOLL
.NUYO Z -nlOSL\S ST.P1E.W
DIRECTOR OF PLaLIC PROPERTY/RCI2.OINO CONLWSSIONER
Workers' Cuinifensation insurance Allidavit: Builderi/Contructurv/Electric(anVPlumbers
\ t alicant Infnrmutinn 1 �/� —7 Ic tse ILL?ihl
:V;IIOC.Inatiths Urgam»tian lndividn.d): ��,��\� a y\A\V
CityrStatc/Zip:_ 'j'
Are you in employer?Check the appropriate bo}�
I.[] 1 am a employer with A• i am a general contractor and t Pype of prof eet(required):
enlplrsyces(1611 and/or part-time).• have hired the sub-conlraetars 6• Now construction
2.❑ I am a sole proprietor or partner. listed on the attachcd.rhecL t 1• ❑ Remadeling
.hip and have nu employees These sub-contractors have e. Oensolilion
working liar me in any capacity, workers'camp, insuraactr. ,
INo workers:comp, insurance 5. ❑ We are a corporation and its ❑Building addition
required.) urOcers have axereised their 10.❑Electrical rcpain or additions
5.❑ 1 ran a hmncuwner doing all work right of exemption per M , I I.Q Plumbing repairs or udditions
myself(No workers'eump. C. 152, J1(d),and wehaveno 12.QROafn:pnirs insurance required.) t employees.(No workers' ;
comp,imurance required.J 15•❑Olhcr ,
\ny applp:uH dW d,v�Ya baa xl mt41 air.,nil out rho vaeliuq below.hawins(hair wrMare'Comport puliry mnumut(on,
'I hvllaawl�Ta who.uhmil,hit UrlAavit indlerina they am doing all, and then hire"Vida reotreelaa moat aotgnlr a new,a1TJavil indlaine
$',mlrnatun that cAsk thin 6ux mwr mash d an adJleararl.hart,hewing the mina a/ihe sub -anjmtun p.pulley In(wma
and thalr workon•cum ruck
tteq.
/urn un anpluyn that/s pruvldlnX markeq'rumprnrgdun Glsurunee/ar my emp/uyrr>< Bduw/s du pulley and Job r11e
i rlla/rllu/lnr4
In.ruruue Company ?Vmne:
Policy d or Selr•ins. Lie. it:
-- Expiration Oats:
Tub Site Address:
CityiStute/Zip:
.\each +copy It the workrn' compensating pulley declaration page(showing the policy number And espiratlon date).
F.liluru to wcuru cuvengd as required under Section 2J.\ ot'MOL e. I J2 can Irad to the imposirian of criminal penalties ors
r.ne up 1 i 1,5C0.00 driller one-year impri.mnmce4 as well as civil penalties in the farm ura STOP WORK ORDER and d tirta
ai tqr as i2S0.(10 a Jay rgainst rile violarnr. Ile advi.:ed that i copy ul'Ihis.rilcment may but furwarded to the 011icu or
Lt e�yliyaUun.r"l Iha rnA I;lr in4uNnee coverngc vuriliealiun.
/dulrvrebyrrrri/y "do the tmrd r}n—ra/—r(r.r.� eau thiat the in�urmullmr ruviJaJ above i•true.
/Pj rY P urJ correct.
/.'//iciv!rr,e�rnly. /7.r,tor i,•rirr in dr Lr �rru, ru be cunrp/rL�J Sy riry ur rarvn.y�Jria(
City err
hrni,q.\ulhorily (rirela n.rc);
I. ;[,card ul Ileahh !. ilr Iluilding I)r 6lrl nicul 1. ('I y Tu,rn Clerk I. i•:It Uri:.11 fngrect,tr i. Dinar bim,, I;H psi lnr
n. Ulh:r
dot Perna:
CITY OF S-VZNi, �tiLISS.ICH(,'SETTS
OULLow; DEP.1A-nt&Nr
I 20 '.1 UNLNGTO,Y 5rXW, Jw FLOOR
rEL. �978) 741.9599
KI,1 C39RLSY OUSCOL L F.Vc(973) 14984
MAYO X fHCi�l li ST.YtP11s
Dixecr04 OP pL aUC PRG PEATY/St:MDLyC COSLNfS31aN EA
Construction Debris Disposai At'fldavit
(required for aU demolition and renovation work)
In sceaidanea with the sixth edition of the State Building Code, 180 C4 R section 111.5
Debris, and the provisions of,btCL a 40, S J4;
Building Permit M is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licemed waste disposal facility as defined by,blCL e
111, S I SOA.
The debris will be transported by:
--T6-AM ��SYYvJ�E
10"no of Aauly)
at debris will be disposed of in
(name o— f fa�`llY),'.�—
f jddreu of
na Nre of permu Lunr P
' \L[ssaehusctts- Dcpartn[cnt of Public SaretY .
Board of Building Rcgul;ttions and Standards
Construction Supervisor License
License: CS 102052"-. _
Restricted to:.00 f - `
FRANK AMATO
4 GEMMA DRIVE
PEABODY; MA 01960 ; r
` v
Expiration: 1/1 51201 3
Cnumtssinu..r - Tr#: 102052
HOME IMPROVEMENT CON OR Type.
H Registration ,�169558 -
dividuaf
Expiration 715/2013
F AMATOy -l,4•_
FRANK AMATO
j 4 GEMMA DR Sy r
Undersecreta
PEABODY, MA 01960\ ry-