32 HANSON ST - BUILDING INSPECTION s
1
V
I 0 e Commonwealth of Massachusetts 11 A FOR
Board
11WWW � Bo of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code,780 CMR USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Min 2011
One-or Two-Family Dwelling
77 TiiiSSechonFo;-OfficialiJseOnlq'=
Bu�ldmg:PermttNuinber ` Jk pateeXpPl4¢d:. (J�
Poa
Budding Official(PnntName) -
' $EC'IfID 1s:SITEIlYFO.. TIO -
1 Property Address 1.2 Assessors Map&Parcel Numbers
LlaIs this an accepted street?yes_ no_
Map Number Parcel Number
1.3 Zoning_Information: 1.4 Property Dimensions:
0 K �
0 Frontage 11
Zoning District - Proposed Use Lot Area(sq R) g ( )
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yazd
Required Provided Required tZone?
Required Provided
11
1.6 Water Supply:(M.G.L c.40,§54). 1.7 Flood Zone Inform 1.8 Sewage Disposal System:
Zone: _ Outside F Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if
SECTION 2 :PRQPERTY:QWNERSHIPt
J�O` wne t of Record: Ma bA-to
MC Q0C I
�Name(Print) ncity,S
t
at
e,
ZIP
✓z- �"�`nY\�'�n bl � � _I-`�-�-rG�1 Email Address
No and�treor Telephone .
...
SEC X IOrI: ;DES4 �xO1K OF PIt(1Pt73WORIC2(ctieek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
Cl\f a\1v�q aY� IV r 'cam IG,n
SECIION4 ESTA4ikTEDCONSTRUCTIONCOSTS
Estirnated Costs Officral Use Only
Item pil
Labor and Materials
1.Building $
1_Burldmg PerindFee $ : Indicate how fee rs determined
Ustand&d, Cityfrown Application Fee.
2.Electrical $ 113 o l ljrojiggt:Cose(Item 6)x multiplier. - x
3.Plumbing $ 2 ;Other Fees;:.$
4. Mechanical (HVAC) $ Itst 11
5.Mechanical (Fire $ T 1W A11Fees $ -
Suppression)
Check N 16 o Check Amount r_Cash AmOuu
6.Total Project Cost: $ l� p patdinFull ' p:Outstandmg Bat anceDue
o ;
SECTION 5 .CONSTRUCTION SEYiVICES -
5.1 Construction Supervisor License(CSL) GI�7� �( 12
Yg p`cGn \-V �7;�� License Number Expiration Date
NamelofCS�LHDIder ListCSL Type(see below)
�_
2 I C (\� IL I Ike Desonptton
No.and Street s U Unrestricted(Buildin MR to 35.000 cu.ft.)
o\c_ e Restricted 18a2 Famil Dwelling
Citylrown,State ZIP M Masonry
RC 'Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
� o-$fo�-��� I Tnsulation
Telephone Email address D Demolition
5.2 Registered Rome Improvement Contractor(BIC) ,(n2 I ) 1 - 1--�I-r
fl •A/1 .� (-ha�g�strlapn� HIC Registration Number Expiration Date
C C 'j ampe or HIC IJ tName
et
Email address
No.and S
414
Ol �aro�oT-fi9c�Y
Ct /Town,State, Tale hone
$EC:TYOlV 6 WORYC>AS'CbMEEN$ATTQN INSIIRa1N,CE AFFIllAVIT(M ...G:
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 budding permit.
Signed Affidavit Attached? Yes .. No I]
BEtTIOIY'Ta 041'NE_ AlaFDORIZATI0NTDBEC0MPLETED:WHEN
0W1alElfi$i GENT OR CC)PITR`CT e1LI'YXESF0R BUYLDING PEiiMIT i
I,as Owner of the subject property,hereby authorize l� X 1(JI� !DLO
to act on my behalf,in all matters relative to work authorized by this building permit application.
r i C C-cl�►t° / S on d
D to
Print Owner's Name lectro c Srgnature)
SECT IQ ( WNERt i)A^U X29 0y ED 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. ( l
C �CiU(1 ?IOYI I te /
Print Owner's or Authorized Agent's Name(Electrumc Signature) _ .. _,.,,......
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.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)
Habitable room count
Gross living area(sq.ft.)
Number of fireplaces Number of bedrooms
ths
Number of bathrooms Number of decks/half1b parches
Type of heating system Number of decks/parches
Enclosed Open
Type of cooling system
3. "Total Project Square Footage"may be substituted frrr"Total Project Cost"
next step living
home elkienoy,made any /
a Nfi
This agreement is made and among
Eric Easley ..-_ .-... Neat Stop LMng,101('NSL-)
32 Harlem St#2 25 Drydock Avenue 5-floor
Boston,MA 02210
Salan,MA 01970-1345.
Custemer ED:C00000037109 Contrad E0:20111209-1 WORK
Site ED:SM02027093 - -
1. DESCRIPTION OF WORKM BE PERFORMED
NSL will perform at cause to be performed the following wodc on the rmstbsrera address above.In a professional mannered In accordance wBhthe terms of
this Contract Including the attached reaonmendetiaohork aderdesaibhig the work In detail(the'Wae.1 which are Incorporated herein by mt8 n
Description Quantity LoeaOon
InsWete MuKFLayer 6birrg,Wag With 4'Dense Pack CdluloBe_—_.-800_....—Living Spme . _ IMP. .
_Slowarpoor Teel,Only„(_Elagrwstic TeetlnaParQ._.._.__....__._.._....___._........?.._..._wA_...__.._............._._...____.___....._.________$80_00...,
Sub Total: $2.172.00
Energy Efficiency incentive $1,629.00
Net bares Tax Agar burned" $0.00
. Total $Sa3.00
1.CUSTOMER a0lrna that they have received no IncenOves during the part 12 months.In81al here
2.The incernit"is depentlent upon the paelmge purchased and/or prior Incentive n Chen�a/�}o Irdlvldud line Items andror
previous IncenWee wary Inaeaee or decrease the size of the Incentive. CC
3.CUSTOMER alflmre that their natural gee pnaVlder Is National Grid Gas.Initlal ham
F�—
T17-
Printed:12MR011 Page 1 eT 1
2. PAYMENT
CUSTOMER agrees to pay NSL for the work as followspayerearrift
4WIf Cad orEch rck deposit Is due etthe fime Ore WaklalpSdO(e.Required payment mmrmadon Mil be csllecNd overthe phone hire asio n ur ervics
reprmeme8ve a<the 0me olanWulmg.Depostm not toezcead 113 of the total retail coats. This contract is not in effect until this depor0le paid by Ore
Conner. (Nate:fvbetenxud,Visa,entl D'ac0ver�eccepletl)
Addlloml Paymaster and Final Imdce:
III paymentsforthe Work ahell be due upon cempknon of the Work
Eck Easley(Dec 15.P0 l 1) Dec 15, 2011 -
ushmerSlg ra yDate
NSL Slgn m Data Nameof NSL Represente0ve
The Terms of this Agreement are contained on both sides of this page
Next Step Living 25 Drydodl Avenue•9s floor•Boabn,MA 02210•(666)867471a•inquby®nexmisplMnghccom•ww amezmmpllviopinamm
}�Document Integrity Verified EmoSign Tmnsedion Number.KXW4M7"K5YXL
a&nssnchusceTs- Department of Public Safety
Board of R,uildinp Regulations and Standard.
Construction Supervisor License
License: CS 91377
s
BRIAN F HESSION'
2 PATRICK RD
TEWKSBURY,MA01876
�6 �•i�E Expiration: 1 01912 01 2
Commizvinner Tr#: 4M
Office of Consumer Affiair5 and Business Regulation
10 Park Plaza e Suite 5170
Boston, Massachusetts 02116
Home lmprove#&nfcontractor registration
Registration: 162111
:.. Type: .Supplement Card
NEXT STEP LIVING INC. Expiration: 1/14/2013
BRIAN HESSION .
25 DRYDOCK AVE. 5TH FL
BOSTON, MA 02210
Update Address and return card.Mark reason for change. _
34104-G101216 Address Renewal ❑ ]Employment .� Lost Card.
lee�ommeoauoemlCd o�✓�aan¢�uattta -
fice of Consumer Affairs&Business Regulation ]License or registration valid for individul use only '
'ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: -
egistration:,,'j%j111 T e. Office of Consumer Affairs and Business Regulation
yP 3 10 Park Plaza-Suite 5179
Expira4mn �4%4ft .
,,._;;;,,,;,•.�,,::.,,_.,: Supplement Card Boston,NIA 02116SSIO
LIVIN�4IQC'" '
CK AVE"
:_5TP;FV"- ��
Undersecretary Not valid withoutsi oture
-�• l,.,rylIUYIYYYn
CERTIFICATE OF LIABILITY INSUKANUr- 11�/2912011
THIS CIE IRCATE IS ISSUED AS A NATTER OF INFORMATION
e ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE .
Ga egher ASSOCiates HOLDER.THIS CERflFICATE GOES NOT AMEND;EXTEND OR
ce Brokers,Inc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Bntic Avenue NAIL#
MA 02210 INSURERS AFFORDING COVERAGE
INSURER A: Ong Bsuon insurance company 21970
Next Step Living,Inc. INSURER a: A.I.M.MUWsI insurance Co. 33758
25 Drydock Avenue INsuRERC: Rlverportlneuro nos Company 36684
19682
5th Floor INSURER o: Hartford Fire Insurance Co.
Boston,MA 02210-2600 INSURER E:
11GE6 RED NAMED ABOVE 1:
)UCIES OF
TERM IAIDIMwCONDITIONOf ANY CONTRACT--- OR OTHER DOCUMENT WITH RESPECT TO WHIC14 HIS CERTIFICATE MAYBE ISSUED OR DING
RTAIN,THE INSURANCE AFFORDED BY HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
ES.AGGREGATE LIMBS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS. P N LIMlfs
TYPEOFINSURANCE POLICY NUMBER EACHOOcuRRENCE $1 OIOO Do
—
GENERAL LIABILITY 792000560 1111112011 11H112012 TD RENTED e1 O 6000
X COMMERCIAL GENERAL LIABILITY MEDENP1AIBem Men e1O)600
CLAIMS MADE FE OCCUR pUMNA &ADV INJURY $1 OO GDD
GENERALAGGREGATE $2 Goo no
PRODUCTS•COMPIOPAGG $1 OD0000
GENL AGGREGATELIMIT APPLIES PER:
POLICY PRO• LOC
11H712011 11/1112012 CDMBINEDSINGLE LIMIT' $1,000,000
AUTOMOBLLEUABIUTY 390001209 (ES eeddenp
ANY AUTO $
BODILY INJURY
ALL OWNED AUTOS - (Per Person)
X SCHEDULEDAUTOS BODILY INJURY s
X HIRED AUTOS - lPerneweld)
X NON.OWNED AUTOS PROPERTY DAMAGE S
(P!radde!1)
AUTO ONLY-EA ACCIDENT S
GARAGE LIABILITY 0T'HER THAN .EA ACC s -
ANY AUTO AUTO ONLY: AGG e
EXCESS I UMBRELLA LIABILITY 792000561 9111112011 11P1112012 BACHOCCURRENCE 53000000
AGGREGATE S3 000 000
X OCCUR CLAIMS MADE
s
DEDUCTIBLE s
RETENTION L WCSTATU• O7H-
ORKERSeOMPoMrONAND 71733244 11/1112011 1111112092 ft
MPLOYEAS•U"LrIT' 1111112011 11II112012 E.L.EACNACCIOENT $500 000 .
HF(P OpRIET R ARIINDED?ECUTNE TBD1OS767 E.L.numsE•EA EMPLOYEE 28011000
�_DTpie@R10 E.L.DISEASE-POLICY OMIT' $500.D00
PEOIFL PROVISN1NS below.
HER
property
08UIJNHX5481 1111912011 11I1112012 $212,594
IPTION OF OPERATIONS/LOCATIONS 1 YENIMES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS
CANCELLATION
IIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLNES BE CANCELLED BEFORE THE EXPIRATION
DAiE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _3p_• ppY1 WRITTEN
Eividence of Insurance
ROMETo HE CERTIFICATE 14OLDERNAMED TO THE LEFT,BUT FAILURE TO 00$0 SHALL
IMPOSE No OBLIGATION OR LIABILITY OF ANY KIND UPON HE INSURER,ITS AGENTS OR
AEPRESENTATNES.
AUTHORREDREPRESENTA VE
The Commonwealth of Massachusetts
Department of lndustrta/Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.covAiis
Workers'Compensation Insurance Affidavit:BuilderstContraators/Electricians/Plumbers and Gas
Applicant Information Please Print Legibly
NAME(Businessforganization/individual) p 1
ADDRESS:
CITY/STATE/ZIP: (O K/�A V �O
Are you an employer? Circle the appropriate number: Type of project(required)
1.1 am an employer with c 4. 1 am a general contractor and I have hired the 6.New construction
employees(full and/or part-time)• subcontractors listed on the attached sheet.These 7. Remodeling
subcontractors have workers'camp insurance. & Demolition -
2.1 am a sole proprietor or partnership - 9. Building addition
and have no employees working for 10.Electrical repairs or addition
me in any capacity(No workers'comp 5. We are a corporation and its officers have 11.Plumbing repairs" "
Insurance required). exercised their right of exemption per MGL 12.Roof re
c.152,section 1(4),and we have no 13.Other (JJ
3.1 am a homeowner doing all the employees (no workers'comp insurance ,
work myself(no workers'camp required).
Insurance required).
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work&then hire outside contractors must submit a new affidavit.
Contractors that check this box must attach an additional sheet showing the subcontractors&their workers comp policy info
I am an employer that is providing Workers'compensation insurance for my employees.Below is the policy and Job site
information. `�M
Insurance Company Name: Y `��cl�< </•'3/ \C`�.
Policy#or Self-ins Lic#: ( I 71733Expiration Date:
Job Site Address: - City/StatelZip
Attach a copy of the workers'compensation policy declaration page(showing thepo/icy#and expiration date).
FAILURE TO SECURE COVERAGE AS REQUIRED UNDER SECTION 26A OF MGLc.152 CAN LEAD TO THE IMPOSITION OF
CRIMINAL PENALTIES OF A FINE UP TO$1,500.00 AND/OR ONE-YEAR IMPRISONMENT,AS WELL AS CIVIL PENALTIES
IN THE FORM OF A STOP WORK ORDERAND 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 COVERAGE VERIFICATION.
I HEREBYCERTIFY UNDER THE P PENALTIES OF PERJURY THAT THE INFORMATION PROVIDED ABOVE IS
TRUEAND CORRECT.
SIGNATURE: 1 DATE I j3 I2
TELEPHONE#;( G03) 31o0' -%s6G
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.Cityrrown Clerk 4.Electrical Inspector 5. Plumbing&Gas Inspector
6. Other
Contact Person: Phone#: