26 GREENWAY RD - BUILDING INSPECTION (2) (.P(0 IK
4^1 The Commonwealth of Massachusetts FOR
F
f4 Board of Building Regulations and Standards RECEITFn
Massachusetts State Building Code, 780 CMR INSPECTIONAt I V O"W ITY
do �Uh Building Permit Application To Construct, Repair,Renovate Or a RevisedMar 2011
One-or Two-Family Dwelling WOW-b A 11 03
This Section For Official UsIOuiy...�
Lf) Building Permit Number: Date plied:
Building Offi.cial(Pri Name) Igna e Da
te
SEi(JIQN4:SITE INFORMATION 1.1 Pro Ur Address: 1?,4 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(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required =Povided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Or- Private 0 Zone: Outside Flood Zone?Check if yes[] Municipal 11�0n site disposal system 0
SECTION 2;rrPROPERTY OVVMRSMP . f
2.1 Owner'of Record:
Name(Print) e City,State,ZIP
?6 61K-tr�5-00g ZOO;
No.and Street Telephone Email Address
777_77777�
all apply}
ION OFPROPOSED w
SECTION 3:'DESCRIPT
New Construction 0 Existing Building V1 Owner-Occupied 191 Repairs(s) 13 1 Alteration(s)%Ef] Addition 0
Demolition 0 Accessory Bldg. El I Number of Units Other 0 Specify
Brief Description of Proposed Work Mo A 0 XI 4v.
- '►-/- I.&� '-k 6�(-%-'
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WPIE!, k-: % ) vtv
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SECTION 4:ESTIMATED CONSTRUCTION
COSTS
Item Estimated Costs:
-iii Use Only
(Labor and Materials)
I r
1. Building $ Fig C)0 C) Building Permit Fee.1. te how fee is determined-
0 Stand ar.d'.6City/T wn 1 .
o.',r Application Fee
2.Electrical $ S 010 0
El Total Project Cost}(Item-96}:x:r multiplier;
k
3.Plumbing $ 300
.2 _Other rFees:,
4.Mechanical (HVAC) $
5-Mechanical (Fire
$ at AD Fees
Suppression) .......
Check No Check Amount- CaArAmotift
6. Total Project Cost: $ 10 71 500 El.O"16 ,'rr dio B1,
SECTION ,CONSTRUCTION SERVICES
. ...
.
4:4 5.1 Construction Supervisor License(CSL) oq9?jq '711412
Cai a,, 20)V 51)r License Number Expiration Date
Name of CSL older List CSL Type(see below)—
0
No.and Street s criptl n,.:,
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
C�tyf-/ ,!-,State,ZIP M Masonry
RC_ Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
q29-3 5 9-9-57s-I c�reqe-v- I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(H][C) / 5-Y � e
(f I-wit,• 3- FUC Registration Number Expiration Date
MC Comp Name OT F11C ReptX Name ee
61 'p"'J"t"o i '?I-V-6 12-R 5-�46 5 !)rg Q:) ke A) /Pt
No.and Street Email address
:1� IVA 01ci 3 3� ?Sz� 5
City�7frow-n, State,ZIP Telephone
:WORKERS'COMPENSATION INSURANCE AFFIDAVIT ikob.Lc- o
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 ...........tf'- No...........0
SECT
ION 7a-:0W.NEK AUTHORIZATION TO.BE COMPLETED WHEN
- - .-
OWNER'S AGENT.OR.-CONTRACTOR APPLIES,FOR BUIOLDRqG:PERIMn .:�.I.
1,as Owner of the subject property,hereby authorize Crd t Ck
to act on my behalf,in all matters relative to work authorized by thi�sbuildmg permit application.
, -YA,
Print Owner's Name(Electronic Signature) 'Date
:7AUTHORIZED�W..OR AUTHORIZED jNtIECLARATION -
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.
R"C"I-j %,.S.- tip
Print Owna's or Authorized Agent's N tronic Signature) Date
1. 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(MC)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
wAkAv mass.gov/oca Information on the Construction Supervisor License can be found at lnwRv ma�s eon/dns
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"
The Commonwealth ofAfassaehusetts
Deparbnent oflnduslrialAccidents
1 CongressS&eet,Suite 100
Boston,Mif 02114-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Elechicians/Plumben.
TO BE FIX"WITH THE PERMITTING AUTHORITY.
Applicant Information Plena Print Udbly
Name(Busmess/oigm i ation/fnd vidual):
Address: 4!5"1
City/state/Zip: �� Sub c(ti Ol M_ .Phone M .�7�3 9-6 9-5-S6
Are you an employer?Check three appropriate box: Type of project(regtdred):
I El Into a employer air .I- employees(full and%rpmt-time).'
7. ❑New construction
2.Q1amasolepropridwmpwmershipapdhavenoempbyaeaworking formein
any capacity.(No wmkm'comp insurance required.) UQ�`••"' -.
required.]3.01 sm a homeowner doing as work myself.(No workers'comp.insurance t 9. Demolition
4.Q I am a homeowner and will be hit*contractors toconduct all work on my property. I will 10 O Bpilding 8dtlitibn.
ensure that all contractors eilher have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with w employees: - -
5.O Iam a general connector and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing TBpe1IS OT additions
sub;contractors have employees and have workers'comp.- ���-t 13.Q Roofrepays.
6.❑We are a corporation and its offices have exercised thearight of exemption per MGI.c. 14.❑Other
15Z§1(4),and we have no employees.iNo workers'comp insurance requhed.) -
•Arty applicant do checks box#1 must also 611 out the section bebw efiowing rhea workers'compensation pobcy iofaimauon.
t Homeowners who submit this affidavit int iCB�g they are doing all Wadi and then hire outside contractors must at a crew affidavit indicating such.
1Contractors that check this box must attached an additional sheet showing the name ofthe su6bn and state whether or not those entities have
employees If the sub-contractors have employes,they mustprovide then wmkws'-comp.poliry.m®her.law an am that is providing workers'compensation hastrancefor my employees. Below is the policy and job site
information.
Insurance Company Name: / 11//- ?L/C(e Or
Policy#or Self-ins.Lic.#: 6 t4 3 Expiration Date: s
Job Site Address: Crreetwq 1\6 C✓1("K City/Statelzip:
Attach a copy of the workers'compensaltion 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 SM.00 a
day against the violator.A copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance
coverage verification. - - - --
I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct.
Signature: Date. 11>16 //
Phone 475-- 3s6- 5-'S976
O1licial use only. Do not write in this area,to be completed by chy or town of/rciat
City or Town: PermkUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
s
Information and Instructions s
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 writtep."
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 then 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-contractors)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 Deparbment 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 burn 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
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POLICY NUMBER (CHUB 2E J 9685 0-15)
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INSURER THE TRAVELERS INDEMNITY COMPANY -0 F. AMERICA
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IPSWICH'MA 019/+38 IPSWICtIJ;b,!iA o19381R
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Insured lS AN INDIVIDUAL ,.(�i'.f`vCL'� , ' '�J�C r;^♦ >LYtct`"t.� _,:Ll+,.:-:-✓.s;
hown;in the sGhedul,
Other work,places and Identification numbers are s e(s)lattac
2 ^.:The pollcy'perlod� is from o5 09 15 to 05 09 16 12 01 A M at the Insured nailing address
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®_ B ^ EMPLOYERS LIABILITY,:INSURANCE .""Part Two of the 16611,600011 tate listed In
item 3:'Al Th6limits of our Ilability'under Part Two are
1 Bodlly Injury by Acbident $ .1000 00 Each Accident, i 1 i
;,Bodily Injury by Dlsease $ 500000 Policy Limit,tf 4�zr
,Bodily injury by Disease:.'..$ , 10000o Each Employee:
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C O 1 HER STATES INSURANCE: Part Three of the policytappltes to the states,,+IfYany listed here . ,
COVERAGE REPLACED BYr ENQORSEMENT WC' 20 03 06A a ,J kL �s g;y
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D This policy includesthese endorsements and schedules �, `, ' t i- }; +
SEE LISTING''OF ENDORSEMENTS + EXTENSION OF 'yINFQryPAGE
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o 4. The p�emldrn for,this policy will be determined by,our,Mad uals of RulQs Classifications,+Rates and Rating
Plans Ali;req`uired Information Is subject to verification and change by audlt to be made ANNUALLY:
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DATE OF ISSUE. ,04_09 15 ''WC
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OFFICE r ORLANDO`INDUS AFF '1 61
PRODUCER +'reERNARD M SULLIVAN INSUR .t.4 lcii t1r4VI1E 7,3iif�JPICEi;: )f }
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Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massach setts 02116
Home Improvement Co�trar�tor Registration
Registration: - 145438
Type: Individual
m Expiration: 1/27/2017 TM 262424
CRAIG J: ROBSON
CRAIG ROBSON " "' ' -= o
61 PARADISE RD
IPSWICH, MA 01938 z r —
r�i
Update Address and return card.Mark reason for change.
Address Q Renewal ❑ Employment Lost Card
SCAT Q nM-0 lI
Massachusetts Department of Public Safety
iBoard of Building Regulations and Standards
7
License: CSFA-048894
Construction Supervisor 1 & 2
Family
CRAIG J ROBSON-
61 PARADISE RD`
IPSWICH MA 01)36�
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Expiration:
Commissioner 09/14/2017