14 GRANT RD - BUILDING INSPECTION (2) A
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4�1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards R E CE I VIE OF
Massachusetts State Building Code,780 CMR I N S P E C T I( N A L�` � t F
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Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling Z015 OCT 23 A C� 0 b
07 This Section For Official Use Only
9 Building Permit Number: ate Applied
/1 Building Official(Print Name) Signature Date
U SECTION 1: SITE INFORMATION
1.1 Pro el Ad(dress: j� 1.2 Assessors Map&Parcel Numbers
1.1 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(11)
1.5 Building Setbacks(it)
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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 err of Rpeco d ( n /y ft6m z�n �`c 1 n (�
Name(Print) ��_G City,State,ZIP
act a
No.and Street t Telephone Email Address
SECTION 3:DESCRIPTION OF PR POSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and�My,aterials
1.Building $ ,SW,a Q 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
O Total Project Cost'(Item 6)x multiplier -x .
3.Plumbing $ 2. Other Fees: $ �
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Licensepl(CSL) r^C �97
�I r IrNoL�,� E`C7a yi License Number Expiraticfii Date tP
Name of CSL Holder
( -I D 1 1 v O 4 L` ��,e // List CSL Type(see below)
l 1( V t�
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
Cityffown, rate,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�Ol 1 p O E�' � �^ SF Solid Fuel Burning Appliances
t+� ,K/ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ` 3 / (a!� I
HIC Registration Number Ex inert n Date
HIC Co an N r HIC e tr t e rnp_ N atn i HIC 7 � l a `, t �-f Ae C�cts� Ae
No.an ltr�e t„��jy(�( ,�/� �/j �1 �j t p �t r
, �C r 4A + , Y V t t C L.l V 1 41� � q IOW/ Email address
City/Town,State,ZIP —J 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 authorize �� (-A— aqd t CSC(
yl
to act on my behalf,in all matters relative to work authorized by this building permit application.
,n15 P �\r b ) '
Print Owner's Name(Electronic Si tatm ) ° Date
SECTION 7b: OWNER`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.
V�&La) W V3
Print Owners or Auttl orized Agent's Name(Electronic Signature) Dalle
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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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"maybe substituted for"Total Project Cost"
I
i CITY OF SM.E:M, NIASSACHUSETTS
BUILDIINGDEP.,,m. NT
.• ' p• 120 WASHIINGTON STREET, 3aa FLOOR
TM- (978) 745-9595
FAX(978) 740-9846
KIUBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECI.OR OF PCBLIc PROPERTY/Bt:mDc4G COw%RssloNER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information {� Please Print Legibly
Name(Business:Organization/Individual):
r
Address: q (21\V �/'-�,
City/State/Zip: r 0 1 Phone hl:
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with 4. 0 1 am a general contractor and 1 6. 0 New construction
"employees(full and/or pact-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet.t 7• [j'IFcmodeling
ship and have no employees These subcontractors have S. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9, 0 Building addition
[No workers'comp, insurance S. 0 We are a corporation and its
required.] officem have exorcised their 10.0 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'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp. insurance required.]
Any applicant that checks box rt must also fill out the section below showing their arorkm•wmpmsation policy infumration.
'11—ow ess who submit this an5davil indicating they arc doing all work mW then hire outside.1 selon mwt fubrnit a new amdavil irdioring Hoch
=Comracton that check this bmc most anadwd an addiliwml enter showing the name of the sub.e mftims and their wohero'camp,policy infmnatioe.
I am an employer that is providing workers'compensadon Insurance for my employees Below Is the pollay and jab site
information.
Insurance Company dame:
Policy q or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/StatdZip:
Attach 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
fine up to S1,500.00 and/or one-year imprisonment,as wall 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 covers•a veritieation.
I do hereby certify a er the pains an e a i of perjary that the information provided above is true and earrec&
C.
(( 1 r,-I� e� Dato:
Phone X: 19�� l9 I - 0�17
Ojjichd use only. Do not write in this area,to be completed by city or(own o)fh•IaL
City or Town: Permit/license#
Issuing Authority(circle one):
I. hoard of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person; Phone#
CITY OF S.0 ENI, bLxSSACHUSETTS
BUILDIING DEPART%i NT
• 130 W.15HLNG'rON STREET, 340 FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KINfBERLEY DRISCOLL
,MAYOR THomAs ST.Pwma
DIRECTOR OF PUBLIC PROPERTY/BUILDIING COMMSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
M rrA�k4� f Ion
(name of hauler)
The debris will be disposed of in
sA1r0 � sfie ';toyi
(name of facility)
(add ss of facility)
signature of permit applicant
ate
Y
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License CS-055357
%`t-e.i is o..
RICHARD L EISM r
47 OLIVER ST ° lu
Everett MA 02149
Expiration
Commissioner 04/10/2016
g'a��lY.°�e�ao�he
Office of Consumer Affairs&Busmess Regulation .
!� We,,1gistriatio
ME MROVEMENT CONTRACTOR
n: ,138680Type:
iration: 8/142015 Ltd Liability Corpc
M.J.CONSTRUCTION!tLC c -
a
RICHARD EISAN ; '.
47 OLIVER ST. •� ! g �:�, �
r
{ EVERETT,MA 02149 Undersecretary
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