6 HERSEY ST - BUILDING INSPECTION (2) t �
I'hu Commonwealth of Massachuscits
n4u Y Duurd of Dui Wing Regulations and Standards CI I'1' OF
(JI t fit; `ALEM
� tssachusctts State Building CuJc, 79D C'hIR
rreti.,edar�,r�nrr
Building Permit Application To Construct. Repair. Renovate Or Demolish a
One-or rna:-f iurrih Du rl(intr
This Section For Official Use Only
Building Permit Number: _ Date A
iv �l vy7'
Ifuilding Official(Print Nmne) S'grtalu Date
SECTION 1: SITE INFORMATION
.I Property Address: 1.2 assessors Slap& P cel Numbers
r
L la Is this an acce ted street?yes no11%lap Nunther Parcel Nuntlxr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed U.se Lot Area(sq II) Frontage III)
1.5 Building Setbacks(it)
Front Yard Side Yards Rcar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c. 40.§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood"Lune? Municipal❑ On site disposal s)arum ❑
Check if es❑
SECTION 2. PROPERTY OWNERSHIP'
t
2.Iw ger of Recgr{IQQ��QN �G PSM Apt C1 r-70
Mum(Print) K City.Slate.ZIP
�es Sc ) repvdavl C0 l �i1—rP rq
No.and Street relephone Email Address J
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all tjh )
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ AltO Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Spccil
Brief Description of Proposed Work': c3�
0
SECTION a: ESTIMATED CONSTRUCTION COSTS
Iteitt Estimated Costs: Official Use Only
Labor and .\huerialsl
I. Building S I. Building Permit Fee: S Indifee is determined:2. Iflccirical S ❑Standard CityTottnApplication FeO Total Projat Cust'(hem 6)x multip _ x1. I'lumhing S 2. Other Fees: S /�^ill\'.W) S List: /� ' ,ire ;_ -�����VVVI'llIVe,",inI rotal .\II Fees: S _ ._.. ._ . .Check No, ( heck :\nluunt: \niuunC
n 1 ntal Project CusC i -- 0 P;tid in Full ❑Ouist ndiog lial;ulce Due:
SE("PION S: CONS'I'RIIC'riON SERVICES
$.I ('onstructiun Supervisor t.icemse(('SL)
K (ne(
N;nnc of l m I folder
r per list l'SI. I'�pe("ec
S"o_ __ LYE-1q� (47�
'—__ f)PC Dcsaripliun
No. .wd Slrvvl
U IlnrestricicJ IlluiWin�s u ro 1S.)00 cu. Ill
— I( I(calricled 10.1 Pam it DwelliCirri fu++n.State,L I' \I �\lasun's Rootin art I n ti
K'S N'inJuw;ulJ SiinSF Sulid fuel BurningAppliances
I InsulationP:muil adD DenudiliunS,2 Registered Home Improvement Contril, j �' n�aP( RP ��( (ileI)� Id IIIC' I(ciiislrltiunNumlwr�BI( I, COMNo.}I IdS tI —�m7_IS/City/Town. Stat ZIPUhuna7/r l/
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 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 .......... Cl No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING PERMIT ,
I, as Owner of the subject property,hereby authorize l((-� C�' 1 R.� r-(" )�am'
to act on a f in all matters ve to Itauthorized by this building permit application.
Il %wef s Naine(Elcorunlc Signature:) Date
SECTION 7b:OWNERI 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.
Prim Ow ncr's ur:\uthurircd Agent's Name(Plccuonic Signature) Dule
NOTES:
I. .\n Owner who obtains a building permit to do his her uvvn work,or an owner who hires an unregistered contractor
(out registered in the Hanle Improvement Contractor(HICI Program),will Lool have access to the arbitration
program or guaranty fund under.M.G.L.c. 142A. Other important information on the HIC Program van be lilund at
m•r, �f .4.1 Information un the Construction Supervisor License can be found at %%tf.f it, yiot ,III,
2. \\'hen substantial work is planned, provide the information below:
rotal flour area I sy. 11.) . ____.-_(including garage. finished basement attics.dvvks or porch)
Gross liv iny,uea 154 It _._. _ Habitable room count
\untherol'hcJruonu - .. .. - .
Ntimberol'hathroolus \unlhcr )I hall,haths
I\pc otltcating system . . . . \'umhcr ul'dccks porches
I\pe0l'c001111gs.NSMIi I!nclo;vd ,.Open
\. "I'oull Project Sgt111re footage" 111:11 I+e tibstit filed lor..1 f1lal Project('flit"
avy OF &. LE.m, NWSACHC:SETTS
�� dL'II�ING DEPARt?(E�T
)_'O WASHLNGTON STREET, 3'a FLOOR
Imo. 978 715.9595
l )
F.kx(978) 710.9844
t p E 2(EY D A ISCO LL Ttimui ST.PIFIRRB
�L�YOZ
DIRECTOR OF PUBLIC PROPERTY/01:I1.Dr`:C,CO\L1IISSIONER
Workers' Compensation Insurance AlVdavit: Builders/Contractor.v/Electrlcians/Plumbers
lipolleant Inform'rtinto pp Please Print Legibly
Nan1C lnusitu+s Urgtmraliaro lndividuaq: �!(+.fI CA.E�- - Pej(0.0/ I[�
Address: so pG=I:Est ) (n0 -A/e--
City/State/Zip: S- ' 0 P one* '7V—_?07—(1/!&
A`r�c�you an employer?Check the appropriate boss Type of project(required):
I.I_a 1 ant a employer with ( 4. 0 I an a general contractor and 1 6. ❑Now construction
amployecs(fhll and/or part-lime).• have hired the subcaniractors
2.0 I am a sole proprietor or partner- listed on the auachcd.shear. t I. ❑ Remodeling
.hip and have no employees These subcontractors have V. 0 Demolition
working tie me in any capacity. workers'comp. insurance. 9. 0 Building addition
[No worker'.comp.insurance 3. 0 We area Corporation and its
required.(
oiticcrs have exercised their 10.0 Electrical repairs or additions
3.0 1 atn a homeowner doing all work right of exemption per MGL 1 I.0 Plumbing repairs or additions
myself.(No worker'Gump. c. 152, $1(4),and we have no 12.0 Roof repairs
insurance required.) t cmpluyees. (No workers'
comp.insurance required.) 13.0 Other
*Ally eppik:un nW shake but II moat 41W NI out the ra-etiuo below showing their wakens'eomptnuslun patios mMrmoaon.
'I Lvnuuwm" sha,uhmil this strleAvil indicatlns thcy+n doing ell work and then hire outside eentmesae si t mhmit a now 3j7ldaeil indicting such
<',�mrxtun that rhak this boa most anachut on.uldiliurvd.hsl showing the nwna a(tM sub.umncwn and their works n'sump.policy inramadoo.
/mn an employer that Is providing workers'compensation brsuranee/or my employers. Below/s the policy and Job slim
iu/onrrulinri A _
In.ucmce(:umpanyNaire: C_e _.._.....
Policy 4 or Selr-ins. Liu. d: Expiration Date:
Job Site Address: Cityislate/Zip:
Altach a copy of the norkars'compensation policy declaration page(showing the policy number and expiration data).
F.liiuru to secure cuvdraga:as required under Section MA of 31GL c. 132 can lead to the imposition of criminal penalties of a
rlrc up to 11,500.00 and/or one-year imprimrImenq as well as civil penalties in the form of a STOP WORK ORDER and a imis
Of up to 52jo.00 a dry against the violator. ire advised chat i copy of thii.ulemcnt may be furwardcd to ilia Office of
Inv c,lig.niuns of the MA fur insurance coverage vcriticaliun.
/da/rrreby cerrr%y under it parrrY-ZIM tbul the iii/brnra/lam provided above i.s irue turd coarser
i r,ourc' r
01/idol r.se wdy. Oa aot Write is this area, m be completed by my at rown of1h ia!
City nr 1'tnvn:__-- _ ._ i'crmilil.lceme i_._. ....__ _ .
Issuiito Atilliorily (circlo unc):
I. lloard of Ilealth '. lluifdi".. I)cp.lrltnenl 1. (ity,Town Clerk 1, b:leetried Inspector i, phimbin:; Inrpeentr
6. 001 r
Cnnlad 1'ervnt: Phone.lt
CITY OF S.u.E.Ni, Akss.ICHusETTS
t3lMDo4G DEP.iA-nunrT
I '0 WASHNGTON STRFSC, J`EZOOI
rM k978) 741.9591
FAX(973) 1449&W
!U1tHE.RLfiY DRLSCOLL
MAMA rRO..%W ST.?MA"
DIXECTO/OP PLa"PROPIITY/BCMDCVG CONOUSMO.rEl
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
N accordance with the sixth edition of the State Building Code, 730 CMR section 111.1
Debris, and the provisions of MGL a 40, S 14;
Building Permit a is issued with the condition that the debris resulting from
'his work shall be disposed of in a property licemed waste disposal facility as defined by 4%,IGL c
I l I. S I JOA.
The debris will be transported by:
Oc vtm Src;I /��V`ft vtG
(nr+ma ut'hoular) J
The debris will be disposed of in :
(n.mtr of facility)
f iddrefr of f�td tY)
iyrtamra o(Permit Ipphcint
.311)7
J it
t� Massachusetts -Department of Public Safety
t Board of Building Regulations and Standards
Cunstru.uun Superr isur .
License CS-093567
MICHAEL J BELLANTE' "e
50 EASTIAANAVE �
SWAMpSC6TT MA,01907
^a 0
Expiration
Commissioner 12/15/2013
OfficeC�on�
--. HOME IMPROVEMENT CONTRACTOR'
Registration: - 156337 Type:
f Expiration 6/22/2013 - -VDBA
s .
MICNAEL J BELLANTE CONSTRUCTION SERVICES
MICHAEL BELLANTE
50 EASTMAN AVE
SWAMPSCOTT MA 01907 e—
Undersecretary