7A GRISWOLD DR - BUILDING INSPECTION The Commonwealth of Massachusetts
�f Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR, 7"edition R O ed Aan ary
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section or Official Use Only
Building Permit Numbe . Date Applied:
Signature: 4 IV
Buildin Commissioner/ peciorof Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
7A 6/l/f ISO%0
Lla 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 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[] p P y
SECTION 2: PROPERTY OWNERSHIP'
2.1/ w�nK.r nofO, �Jor "!a Gaa�oo• T••sf /9 6/L2.5AJp/p
Name(Print) Address for Service:
as 1,38-3 I
Signature Teleplione
SECTION 3: DESCRIPYfON OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building V Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':__ •g
��i� b.9nN3 • �iJJa, � �a J .f7�5 CnJ.Jl •�9 L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I.Building $ 8� 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ I/Total Project Cost'(Item 6)x multiplie .3 A* x
3. Plumbing $ 2. Other Fees: $ y�
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount:/ Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1Licensed Construction Supervisor(CSL)
Q)111-4rn 51eo6t,,,.ps License Number xptrtion ate iJ
Name of CSL-Holder
A-,/ �o. /ta N it) 3� List CSL Type(see below)
Adr ss Type Description
L64' OP /h/9 U Unrestricted(up to 35.000 Cu.Ft.
Signat e R Restricted 1&2 FamilyDwellingMInstallation
M Mason Only
RC Residential RoofingCovering
Telep e 99 WS Residential Window and Siding
SF Residential Solid Fuel Burning
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) p / C [�
S.C�o4"J �'-eO ZI C / .J 6 / 7
HIC Como-any Name or HIC Registr t Name Registration Number
/3. rr,.9sm.✓ 3�
Address
Xroadn ^ov �l�d y� r Expiration Date
Signatur Telephone
SEC ON ORKERS'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 Issuan of the building permit.
Signed Affidavit Attached? Yes ..........V No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application. _
Signature ofJDwner Date
SECTION 76. OWNEW OR AUTHORIZED AGENT DECLARATION
1, A-Q11;0 0-h ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
-..L191�1 rit�m ZT
Print Name
s is -i D
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
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(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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 1 I O.RS,respectively.
2. When substantial work is planned, provide the information below:
Total floors 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"
i CITY OF S�UEM, 2UNSSACHUSE'ITS
BUILDING DEPARTSIENT
• ` 120 WASHINGTON STREET, 3'a FLOOR
TEL (978)745-9595
FAX(978) 740-9846
Kl%iBERLEY DRISCOLL
MAYOR THo"ST.Pw8.Rm13
DIRECTOR OF PUBLIC PROPERTY/BL'tIMING CONWISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 ` Please Print Leeibiv
Natne(BusitnssOrganizatiorulndividual):
Address: 13• A rojaA� s 7
City/State/Zip: 4LOAP& %1t6 PZYev Phone#:
Are y u an employer?Check the appropriate box: Ty
pe of project(required):
1. I am a employer with 4. 1 am a general contractor and 1
employees(full and/or part-time).
+ have hired the sub-contractors 6. New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ?• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers'comp. insurance. g. El Building addition
[No workers'comp. insurance 5. We are a corporation and its
required.] officers have exercised their ME] Electrical repairs oradditions
3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.[No workers'comp. c. 152,§((4),and we have no 12.[] Roof repairs
insurance required.]t employees. LNo workers' 13.❑Other JC/9a
comp. insurance required.]
•Any applicant that chocks box N I most also fill out the section below showing their wmim s'comptnsmion policy information.
r I itmeowners who submit this affidavit indicating they are doing all work and then hire outside comments most submit a new affidavit indicting such
:Contranon that check this box must attached an additional sheet showing the name of the sub mrwtors and their workers'comp.policy information.
i um an employer that Is providing workers'compensation insurance far my employees. Below is the policy and Job site
information tt _
Insurance Company Name: CZna�w))7br 4ZP aZ24
Policy#or Self•ins.Lic.#: �G ji Q1 ! 8'tS Expiration Date:
Job Site Address:_�a 6n/SiJ>/� tC Bnra� City/StateiZip: 40,kor►.rnl-
Attach a copy of the workers'compensation policy declar t 10 p1e(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 a
fine up to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigmions of the DIA for insurance coverage verification.
I do hereby certify under t/re pains and penalties of perjury that the h formatlon provided above is true and correca
Si nature: as�a.+-+— Date: l O
hon #;
Official use only. Do Prof write in this area,to be completed by city or row"official
City or Town: Permit(License
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other _
Contact Person: _..._....__.__.._� Phone#:
CITY OF S.0 ENM, T%L-�SSACHUSETTS
' BUUDLNG DEPARTMENT
130 WASI-INGTON STREET, 3w FLOOR
T EL (978) 7.15-9595
FAx(978) 740-9846
KIJLBERLEY DRISCOLL
MAYOR Txoatas ST.PtsRRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LINQSSIONER
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:
�FA�iSopd-
(name of hauler)
The debris will be disposed of in
AA,sj
(name of facility)
Aoxs,� a7a7tis7n„W) /°fta
(address of facility)
signature of permit applicant
J ^Ode/ �
date
a�nir�tri�c
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Rear 170 Lynn St. _
Peabody, Kh 01960 a s
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7a Griswald Drive io r■sa■�es�a■ae■+aa�scs■as■aoa�aaa>.cea�csr■ac
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Nussachuwtis- DeR`,ulali m.f nd St:oilards
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Construction Supervisor License
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License: CS 84452
Restricted to: 00
WILLIAM J SKOURAS
R 170 LYNN ST
pSABODY, MA 01960
Expiration:
Tr#: 9736 9738
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