20 HORTON ST - BUILDING INSPECTION 2% The Conunomveakh of Massachusetts
Board of Building Regulations and Standards Cl I'1'OF
Massachusetts State Building Code. 730 C'MR SALEM
'L,•• Reri,ceJ.11ur'nl/
Building Permit Application 'ro Construct. Repair. Renovate Or Demolish a
One-or Two-Fantill•Dwellin.Y
This Section For Official We Onl
Building Permit Number. Date:Applied-
Building Official(Print Niunc) Siytature �lyibmc
SECTION I: SITE INFORMATION
1.1 roper( AJdress: 1.2 Assessnn Map& Parcel Numbers
h
I.Ia Is this an accepted street?yes X- no blup Number Parcel Nunitkr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Imposed Use Lot Area Isq 11) Frontage IB)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.1.c.40.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal Check fif es❑ P s)stem ❑
pw A'o SECTION2: PROPERTY OWNERSHIP'
N;une 1 Pnnlj City.Slate.ZIP
[-6(4-pa S--
No.and Street - rclephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other Specify:
Brief Description of Proposed Work=:
BUG
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S 1. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S ❑Standard City,/Town Application Fee
❑Total Project Cost(Item 6)x multiplier
lier
3. I'lumbing S
. Other Fees; S — �•�
J. Mcchanical tll\'.1('1 S List:
5. Mechanical tFire
eu,+ression) S Total .\II Fccs: S _
Check No. _ _Cheek Amount: C.uh \nnnun:
Total Project Cush S Z ❑paid in Full OOutstanding Valance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 C'onstruction Supenisor License(C'St.) �00c{
I.icvaw Number P\piratil 1 Date
` Nantcull'SI. Ihdder 'A_, �----
3 ®6*� dwc� I ist l'SI. I)pe Isee hduts l
No. and5trccl -�---- - - Type Description
® C '76
--- (I 1 n irict d 1 I llui Family
ys li to i'19 10 car. IL1
- sl is R Res%laso ry Lrl Pamil Dllcllin
Cil)i fatty,Sl;tle.LIP ,\i 11;uon
KC' Ktwtin C'o,rorin
._.—._ µ'S N'inJutr;mJ SiJin
(� / 7,�r 9 .Solid fuel Ilurning Appliances
ci �G �C-` ( 'I l MOO (OGUCd-ur I Insulation
Zell hnne [:mail addrcss D I7enullitiun
5.2 Registered
��Home
rr�improvement Contractor(HIC)
cu aA �Ur I IIC Registration Number r.epirution Uulc
I I C'ol w nn•o IIC'1!• tatrant Name
Nu. �M "A ^„�40 '7� [.1?Y1-- .A7fa ���r EI11alI aJJR1tl
City/Town./Town• State,ZIP ,—r U ` rella hone 7�L
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this aff davit 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 FORFOR BUILDING PERMIT
I•as Owner of the subject property,hereby authorize f t1 W6't1C1'
to act o�n mpy behalf,iin'' all mattterrs,s relative to work authorized by this building permit application.
Print wner's Nume(Electronic Signature) to
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering Illy 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.
C 8
Print 1 ancr s orrAuthorircd Agent's ante I I:lectronie Signature) ate
NOTES:
I. An Owner who obtains a building permit to do his.her own work•or an owner who hires an unregistered contractor
(llot registered in the Hume Improvement Contractor(HIC) Program),will LUd have access to the arbitration
program or guaranty fund under.I.G.L.c. 1 42A.Other important information on the HIC Program can be found at
t,wtt ,-,,i Information on the Construction Supervisor License can be found at 1p,
2. \\'hen substantial work is planned•provide the inrormation below:
Total fluor area Istl. R.) - I including garage, finished basement attics,decks or porch)
Gross living area I sq. 11.1 . __. Habitable room count
Numberollireplices Numberol'bedrooms _
Number of hathrooms _ _ Number of Irdf haths
11 pc of heating s�stem _ . - Number of decks, pordles
I\pe of 000llllg S1 itelll I:ncloscd _ --01'en
1. -ftdal Project Square Footage-nia) he submititled ILr"Total Project Cost"
The Commonwealth of Massachusetts
t
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information pp��s�t p t''r h �/ Please Print Legibly
Name(Business/Organization/individual): 1-1 as,� WtLp �P4 t I?,A 116 N
Address: 3 1-l'GtAA� "e--- 1
City/State/Zip: "J Phone#: 719- 34 7/
Are on an employer?Check the appropriate box: Type of project(required):
1.l9' I am a employer with T 4• ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2 ❑>I'am,a.sdle proprietor or partner- listed on the attached sheet.t �- ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
workingfor me in an capacity. workers' comp.insurance.
y p y 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised thew t0.❑Electrical repairs or additions
3.❑ J aria a homeowner doing all work- right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152,§t(4),and we have no 12.❑Roof reps.
insurance required.]" employees. [No workers' T3.XOther 4t v comp.insurance required.] ""`
Any applicam that checks box 41 must also fill out the section below showing their workers'compensation policy information. -
r Homeowners who submit this affidavit indicating they are doing all work and[ben hire outside contractors must submit a new affidavit indicating such.
Contractors chat check this box must snitched an additional sheet slowing the name of the sub-contractors and their workers comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Insurance Company Name: V^�� r-�'/q
Policy#or Self ins.Lie.#: �✓ J .* 11c r_''� RA /3 Expiration Date: 3
sJob Site Addres r f) ✓71 City/State/Zip:
Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required trader Section 25A of MGL c. 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 ORDER and 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.
1 do'hereby certify under the pains and penalties of perjury that the information provided above
� truu and coned.
Si nature ?,- Date /21
Phone#: 7 �rt 3 Y
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit[License# i
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r , s d�,Bu
OflTce of Con nn sumo Affairs .Business 2cgu Lrcion
FrR4HOME I MPROVEM ENT CONTRACTOR Type.
{�t.�,teg istrati on: 111617
ru "Expiration: 1/12/2015 Private Corpora..
RICHARD LAMBY
3 OC:EAN AVE
SAL_M, MA 01970 lh;dersce reou'y
1921 ..
('nm l ru r 0 ant Su pen i I SpCCIII is
CSSL-102293
�1
RICHARD LAMBY
3 OCEAN AVENUE
SA.LEM MA 01970
05/03/2014 \