3 HORTON CT - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pplied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property A ress: �L 1.2 Assessors Map&Parcel Numbers
3 Lmb✓ oN C_i
1.1 a 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided .,,T
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 fff1� Private El Zone:
if yes❑ Municipal Von site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2 f Re
Eecord.
.UeSir
Name(Print) City,State,ZIP
'e/— .� �' 9757 fiS7 �//6 9 al. / ez� ��yi l�rjl
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) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work2:
a>—
a o I ;eg- L 5
�i4 4 �i re cal iY/ a /69c Aa✓(,��j
SECTION 4: ESTIMATED CON RUCTION 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: $ '✓� � h
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
4 q 3 1 License Number' Expiration Date
Name of CSL Holder 1
Sk Llve o A n List CSL Type(see below)
No.and Street IV I�'l1 A t. T e Description
3 N1 /1 n U Unrestricted(Buildings u to 35,000 cu.ft.)
� rl,
v R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
S�p nX G )na t ' Q% WS Window and Siding
'1 ''") SF Solid Fuel Burning Appliances
Q—) / �� a7S I s /I rO i `( AA 1 6101 I 1 Insulation
Telephone I I D Demolition
5.2 Registered Home(Improvement Contractor(HIC) 15(�2 -21 U -,
HIC Registration Number Expir wn Date
HIC Comp Name or HIC,Registrannt Name I�,,��II , jt/f
.3g /yl o-Nfi V C1.lR, NyQ, �'I` l ON V W D-, •
No. d SVeet (a Email address
S�tr,.e L,,e,.,N. Vln.e. )7 �)� a7�
City/Town, State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 9 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
1,as Owner of the subject property,hereby authorize t�13o rril d S.H- Sgr ;k l'LI'sh' ( -OI')
to act on my behalf,in all matters relative to work authorized b�this building perumit application.
2�d ) tpQ&,/, ffie. lr P A• MelP> 1/IR113
Print Owner's Name Electronic Si ture) 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 his application is true d accurate to the best of my knowledge and understanding.
Print Owner's or Authori Agent' ame(Electronic 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/des
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basementlattics,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"maybe substituted for"Total Project Cost"
v
VI t++tLhu ctt+ Dyiartment id Public S'tfe"
41 . Ro u d of BuildingRc ul t[ums.;ind St uul.u;tl+
# Y Construction Supervisor License
r
License: CS, 74839
STEVEN M' SGROI f't' tsl 4
21 VERNON ST
WOBURN, MA,01801 " f
Expiration: 4117/2013' '
1.'aumrisioori Trti ;17782
? , �Oltice of Co sume�Yi e�l�ain 8c.z8 sm� a oo '
�'. TROS.
HOME IMPROVEMENT CONTRACTOR.'` `
Registration ?15671 Q- . '`Type
Expiration 7l3112013 DBA
Ids I CONST . t'iTl N ,
STEVEN SGROI -
� '' 38 MONTVALE
s- STONEHAM,MA 0218Q i�l Undersecretary --
Ii
�4..y..y...ax.d ... `.�afuurz®r isLri.o✓w. .u.�wry -reran..'+r.A.ka a...
CITY OF S:U.Em, iNL ss.AmLSETI'S
s ' - BUILDINGDEPIRTII&NiT
} ' 120 WASHIN1GTON STREET, 3"'FLOOR
use TEL (978) 743-9595
FAX(973) 740-9844
KISf3FST Y DRISCOLL
.MAYOR THoatAs StPtEaR13
DIRECTOR OF PUBLIC PROPERTY/BUILDLNIG COSL\IISSIONER -
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Antillcant information Please Print Legibly
VII111C(Busitxyi.Urgani:uiorulndividual
Address: o / 1
City/State/Zip: 4elf�e.kcl "V\ Phonell:7Are you an employer?Check the appropriate bast Type of project(required):
I.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6, 0 Now construction
employees(tall 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 subcontractors have V. 0 Demolition
working for me in any capacity. workers'comp. insurance. 9. Building addition
[No worker+'comp. insurance S. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.) officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workers'camp. c. 152,41(4),and we have no 12.(] Roof repairs
insurance required.)r employees.[No workers' 13-El Other
comp.insurance required.)
•nny uppllc:ue duo chucks box sl must also all our the sectius brow shawiny their wrorkan'<amgnudun pulley infurm611on.
r I hvnuuwnws who suhmir this a0davis indicating they are doing oil wart and thou hits outride canine.mtel submit a new afildavil indicating such.
:Contractors that cheek this box must anoehod as addidund+hmr showing tho name of the rubaronineron and their workers'camp.policy infotmadoo.
i urn an employer that/s provlding ivorkers'comperrtadon lusurance jar my emplayeex Below is thePolley and Job sUe
infarmatlant. -
Insurance Company Noire,
Policy it or Self-itu. Lic.B: Expiration Outgo
lab Sire Address: City/Slate/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 23A of NfGL e. 152 can lead to the imposition of criminal penalties of is
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to SM.00 a Jay against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Invesiigmimts ol'the DIA for insurance coverage veriffeafiun
/do hereby certi/y rrudde the paint and pmroltlds u/per/ury r/rut the Ltifurnrarlon provided above is true and carrrrt
Sicndmre! ,. A<\ Da ro, Oao13
Phone,*
O/)trial use ordy. Do not write in thls ante,to be completed by city or town n//Ielad
City ar'fown: _ Permit/l.lcenseq
Issuing Authority(circle one):
1. Board of liealth 2. Building Ilepartntent i.Cityffnwn Cierk 4. Electrical faspector 5. Plumbing Impector I
6.Odter
ICon face Person: _.. Phone tk
F
F
f ..
, "rive
CITY OF SALE\t, NWSACHUSETTS
8LLLDL\G DEPARTNI&SIT
1 '0%V-NSHLNGTON STRE "ET, 3 F-OOft
� = TEL (978) 745-9595
F.kr(978) 740-9346
c[�t13ERL£Y D1tISCOII.
llti.yOR TEIOSIAS ST.PIERRS
DIRECTOR OF PUBLIC PROMTy/SUTIDING COSLN/ISS1oNER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft this work shall be is issued with the condition that the debris resulting from
l 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by NfGL c
The debris will be transported by:
(name of hauler)
'['he debris will be disposed of in
_—
(name ot'tacility)
(address of t'jcfhty)
signature of permit ap✓✓✓ -ant
datedate