7 HAMILTON ST - BUILDING INSPECTION IO
The Commonwealth of Massachusetts
n Board of Building Regulations and Standards CITY OF
L l W Massachusetts State Building Code, 780 CMR SAL"
Revised A&2011z
N Building Permit Application To Construct, Repair, Renovate Or Demolish a
_ One-or Two-Family Dwelling ac m
This Section For Official Use Only m
n Building Permit Number: Date Applied: m
1 ) o
` Building Official(Print Name) Signature I Ui Pate Z:;
SECTION 1: SITE INFORMATION in
C- 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
'1 1/AM ILi On/ SST, SA pi MA
1.1 a Is this an accepted street?yes s/ 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?Check if yes[] Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of Record:
CIAR Lo T TA T nz-g U I SALAnM MA -0 19 -70
Name(Print) City,State,ZIP
`J. HAv)t/LTo.r Sr S4GEM M A
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work 2:_(dA;�M DAMAGE RCM i AW6 /_ooR.
1 'VAU-j A& ryoIIE iris �o AAw 44dtAg5, iM w iER
A2FAc C��.r� .eE,PAIR ND NEH/ LIC'L/Tc'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only ,
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:-$
Check No. - Check Amount: - Cash Amount:
6.Total Project Cost: $ / pp p ❑Paid in Full ❑Outstanding Balance Due:
MA -r-o posC�oor�
M�iL�D -7 6tl(y
t
SECTION 5: CONSTRUCTION SERVICES
t 5.1 Construction Supervisor License(CSL)
CS- o9l 6 *3 tos 78 z0l7
PA rA I CK M b 56 0,0j2 License Number Expiration Date
Name of CSL Holder U
List CSL Type(see below)
No.and Street Tye Description
M A o 1 Q4's Unrestricted(Buildings u el ing cu.ft.
z`"t R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
'MI.' 40 100 PATAidtpO$C0DCo�»Patu E$CWA I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /3`f ,,10 /O
p/)%R I CX 5 GOOD HIC Registration Number Expi tion Date
HIC Company Name or HIC Registrant Name
4 y G,ox .P�N RoAo
No.and Street Email address
— Sh 0 MA � / Ir83 9�IS�I'1o ��0] »arrlcK@ogGmap cn,.aP/ant� oM
Ci own,S ttate,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 authorize je4 TAICK O,S6dOo
to act on my in all matters relative to work authorized by this building permit application.
Y I t l2 /J
Print Owner's Name(Electronic Signature) 'Le, T f A T �, Date
SECTION 7b: OW Rr OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the ins and penalties of perjury that all of the information
contained in this appl' on is true and accurate to the bes f my knowledge and understanding. /
1 I F Z/ tJ
Print Owner' onze Agent ame ctrome Signature) Date
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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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 halfibaths
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"
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-091643
Construction Supervisor
PATRICK M OSGOOD
PO BOX 1111
MARBLEHEAD MA 01946
Expiration:
Commissioner 05/28/2017
,
Office of Consun
lOF
Bosto
Home Impra
OSGOOD PAINTING SERVICE:
PATRICK OSGOOD
PO BOX 1111
MARBLEHEAD, MA 01945
SCA 1 C, 20M-05111
Otfiee of Consumer Affairs&Business Regulation
(.HOME IMPROVEMENT CONTRACTOR
Eegistration `134220 Type:
xpiration 10/12/2017 DBA
OSGOOD PAINTING SERVICES .
1 y�
PATRICK OSGOOD
44 FOX RUN RD.
TOPSFIELD, MA 01983 Undersecretary
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
UT 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): OS6COL) PA /M%IA/ / 460 e-eN:JA4C IAI ,:%5?V1 z5
Address: Po 0 o r l 1 //
City/State/Zip:A44AR).El/4I/J MA Phone #: 2 '7*v 1 o o
Are ou an employer? Check the appropriate box: Type of project (required):
1. I am a employer with 1`0 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 L❑ 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'
comp. insurance required.] 13.0 Other
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeownen who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the time of the sub-contractors and their workers'comp,policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �—"- "-
Insurance Company Name: rt[—M MI/;y,4L -T1V5YdAdej5 C0M13A14
r
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: H M/t-i ON S% IZA4 MA _City/State/Zip: MA O /9 7 O
Attach a copy of the workers' compensation polic, declaration page (showing the policy number and expiration date).
Failure to secure coverage as required trader Section 5A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, 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. Be advis d that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage ver ication.
I do hereby certify under the n nd allies of erjury that the information provided above is true and correct.
Si nature: Date:
Phone#: q l y 7 O l O O
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#: