17 HEMENWAY RD - BUILDING INSPECTION (2) t3 - Itd - o llq� U� 3CAC4 I
s� The Commonwealth of Massachusetts
' Board of Building Regulations and Standards TORE,C a�E ITy _
Massachusetts State Building Code,780 CMR IN$PEGfE}N . L
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or D t
One-or Two-Family Dwelling
This All= "39
This Section For Official Use Only
Building Permit Number: Date Applie
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Pror Address: 1.2 Assessors Map&Parcel Numbers
FIfIh[/1wln--f�
1.la Is this an accepted street?YeLvs= 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 Rem 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 Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
(1 SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne fRecord• ��f �� 7D
/iM, t �(1 t� L (V3tg r vl,/
Name(Print) City,State,ZIP
I-? VVtVn-cnwk
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
.. New Construction ❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s)�114— Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 0 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: $ .�pQ ❑Paid in Full ❑Outstanding Balance Due:
zot
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) S c19 040
M 1 c F'I /�Et— j2. -b O 120N License Number Expiration bate
Name of CSL Holder List CSL Type(see below)
He; ftA(2-1 S"TRl-:E"T
LL-
No.and Street Type Description
6 t=U i<(LL�-I +v1 A C> F1 1 S U Unrestricted(Buil ings up to 35,000 cu.R)
Cityllown,Stale,ZIP
R Restricted I&2 Family Dwelling
M Masonry
RC _gRafin&Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
(;)W922gg1y3 I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) I H In 1-1-1 3 1 z4s 1 i1
l Re l'f'OI H C1-me (Q HIC Registration Number Expiration Date
HIC C N ompany ame o r r HIC Registrant Name
�-1t I-4R0.Z ST2tc�'T MtkcC'.-lhchouscwri
No.and Street Sh1'ro.0
FSt5u�2L�1 MA o19tS 9-)1S92z-9C,U23 Emaladaress
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 ..........(1211 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED 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.
J
Print er's or Authorized Ag=Vs Name(Electronic Signature) DAe
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 fiund under M.G.L.c.142A.Other important information on the HIC Program can be found at
'aca Information on the Construction Supervisor License can be found at:t'r z..raa,.2n�!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.fL) 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"
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
License: CS-059906 [+'
NIICHAEL R DOIj ON
PO BOX 247 . ; I
PRIDES CROSSING MA.101965
it
i
� suite'
Expiration
C
1
Commissioner 0710512016
pj"`
i-3. Tn,�; Office of Consumer Affairs and Business Regulation
J
10 Park Plaza- Suite 5170
`-- Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 146121
- Type: Private Corporation
Expiration: 3/28/2015 Trn 238086
THE HOUSEWRIGHT COMPANY
MICHAEL DOIRON
P.O- BOX 247
PRIDES CROSSING, MA 01965
Update Address and return card.Mark reason for change.
Address E] Renewal ❑ Employment Lost Card
SCA1 0 WMW11
V/ee oveo�ra,rraenl�/c afc.�/..�une/rruelF� License or registration valid for individat use only
Office of Consumer Affairs&Business Regulati on -
m� OME IMPROVEMENT CONTRACTOR before the expiration date- If found return to:
-'' $egistrahon• -146121 Type- office of Consumer Affairs and Business Regulation
t - _1 10 Park Plaza-Suite 5170 -
` Ex Boston,328120t5> Private Corporaticn Boston,MA 02116
THE HOUSEWRIGHTCOMP41 > -
,r'
MICHAEL DOIRON -
45 HART STREET
BEVERLY,MA 01915 - Undersecretary Not valid without signature
C S CD SCt �b�
CITY OF SM.F.M. 1N'LkSSACHUSETTS
BUILDLIIG DEPARTMENT
N• 130 WASHIINGTON STREET, 310 FLOOR
T EI- (978) 745-9595
FAX(978) 740-9846
[uNC3EPj FY DRISCOLL
N AYOR T Homm ST.PmRRE
DIRECTOR OF PUBLIC PROPERTYIBUMDING CONMUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMM 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:
(name of hauler)
The debris will be disposed of in :
Ise
(name of facility) /
(address of facility)
signature of permit applicant
date
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