4C HART WAY - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 20/1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Da AAppplied:
TA"
4
Building Official(Print Name) Signature Dad
SECTION 1: SITE INFORMATION
1.1 r pertyAACd_ddress: 1.2 Assessors Map& Parcel Numbers
WAY
I.Ia 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 R) Frontage(R)
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:
Zone: _ Outside Flood Zone?
Public Private ❑ Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recor
I NNF SC+' 05SE6k6 SALE11 NA olg'10
Name(Print) City,State,ZIP
GC PAKT -tom N J1g-140 - IM T
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building) Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Prop sed Work 2:
Ktsnave TVK ( KW-WK CAKIN . -ViLI S:_H12WK rAw sc Kfv��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 'S Q0o 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ [I Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
L
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ S p00 0 Paid in Full 0 Outstanding Balance Due:
` SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 61 Q S^ j2
[ 'A52- [r Vn ONO License1 Number Expirfiticull'Date
Name of CSL Holder { r
IS NI[ 00 p� List CSL Type(see below) V
No.and Street hh Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
IhlllGZ t I `1 R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
AIDS-2 -'t SF Solid Fuel Burning Appliances
1 aI` 1 "q[T2 / I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)ij A - ' /6
HIC Registration Number xpira ton Dx[e
HIC Company Name or 1-II Registrant Name
IS t�ltsi;lNT �ni iNFo � NoVA '—CP� .GaF1
IIVIStreet
L_E Ko( MA QI Vtl� 'Igl Email address
City/Town, State,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 ..........Iq 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
L Kriw- ! COLO :59ff6 CA
Print Owner's Name(Electronic Signature) ate
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
containediin this application is true and accurate to the best of my knowledge and understanding.
-
TO-NPSZ 6cNo L 2e 17-
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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
AAA.mass. ovp /oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemen /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"
CITY OF S-UE,hI, `fLxss.A cHLSETTS
BL'ILDLNIG DEP 1RTJIENT
• j p 120 WASHLNGTON STREET, 3m FLOOR
'I'M (978) 745-9595
FAX(978)740-9846
N fBE31 EY DRiSCOLL
MAYOR THOhtAs ST.P[ERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COM\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Naine(Busitx� Organizat''ittowin/dividual): NOVA �OKIj-fy�, & {NO�EL)l�6 lt�L,
Address: 'S n1 V h[N S f
City/State/Zip: I1RPI M II 1AR Phone
Are you an employer?Cheek the appropriate box:
Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
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.: 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
f No workers*comp. insurance 5. We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I i.❑Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp. insurance required.]
•Any applicant than ehaka box rt most also fill out the section bclow stowing they workers'compenamion policy infumtation.
*I bmteuwoxns who submit this affidavit indicating they am doing all work and then him outside contractors most submit a new affidavit indicating such.
:Comrmxoo thus check this box must anached an additional sheet showing the name of the sub.,ont"ton and their workers,comp.policy information.
I am an erployer that is providing workers'compensalion htsurance for my etnplayees. Below Is the policy and fob site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date: '
Job Site Address: City/State/Zip:
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 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 lac forwarded to the Office of
Investigations ol'���ih'''e �DIA for insurance coverage verification.
I do hereby r t1yyy ur der the pains and penalties of perjury that the infornrallon provided above J)is true and correct.
Siena tire: Date,
P m #;
Official use auly. Do not write in this area,to be completed by city or town ofrci tt
City or Tuwn: _,,__ PermitfLicense#
Issuing Aui purity(circle one):
1. hoard of Ilealth 2. Building Department J.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ _ _ Phone#
1
�la,vtcituxU� - Ocparinicni of Public �'afelc
Board off Buddinr_ Rcr ulatifm and % tanffarfk = Boar' oAwittyingRegulahofis end 3tand'ards
Construction Supervisor License HOME IMPROVEMENT CONTRACTOR
License: CS 89905 t
. �� � � Registration: 146850
Restricted to: 00 Expiration: 5/20/2011 Tr# 283580
TOMASZ A WABNO Type: Private Corporation
;I
15 HIGGINS RD } NOVA CONSTRUCTION & REMODLEING, INC.
MARBLEHEAD, MA 01945 TOMASZ WABNO
15 HIGGINS RD.
Expiration: 6/4/2012 MARBLEHEAD, MA 01945 Administrator
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