10 IRVING ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts RECE�V�p
k Board of Building Regulations and Standards ECTECNAL SE v'C65'ry OF
M1?Massachusetts State Building Code, 780 C
eReuLvAd Mar 201
r J 1
Building Pen-nit Application To Construct, Repair, RenovatW Qe#VeJfZh qA UU
One-or Two-Family Dwelling IIP�
This Section For Official Use Only
Building Permit Number: J Date Applied:
zz
Building Official(Print Name) 5 nature D, e
SECTION I:SITE INFORMATI
1.1 Pro err���r�� L 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted s reel?yes j no Map Number Parcel Number
1.3 'Zoning Information: G � % IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Ynrds Rear Yard
Required Provided Required Provided Require) Provided
L6 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 ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP!
2.1 Owne � f 1 or
Name(Print) City,State,ZIP
/ 0 �-Ay1'K-)
No.and S Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ F-sis[ing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specil'y:
Brie' escription gfjl'�po a Work2: C
�r G O
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ Z _ 1. Building Permit Fee: $ Indicate how fee is determined:
O ❑ Standard City/town Application Fee
2. Electrical $
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ (J 2. Other Fees: $
4. Mechanical (IiVAC) $ List:
5. Mechanical (Fire $
Su ressioo 'Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ���� ❑ Paid in Full ❑ Outstanding Balance Due:
Co N--V-1,cs�-o Vz-
I �,
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction�superv""i�/sor,License(CSL)
QJ '' License Number Expiration Date
Name ofCSL F older
/', 't U. 7—v� n (�— — List CSI-Type(see below)
No.an TYPe Description
Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/� Solid Fuel Burning Appliances
/ / J /1�1/( I Insulation
'I'ele hone Email address U I Demolition
5.2 Registered Home Improvement Contractor(HIC) 13,936
j
42/� Joy/So d'UCr�d� HIC RegistrationNumber Expiration Date
IIC Company Name or li�tegistrant
No.and. reet J n�„ /S/,2 � Email address
City/Town,State,ZIP 1 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 .......... ❑ 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: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
UU i A_X-6va4�ID dIr�/
1 r nt Owner's or Authorized Agent's Name(Electronic, gnature) 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
www.ntass.eov/oca Information on the Construction Supervisor License can be found at www.ntass.gov/dus
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. 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.U-ENI, NL' sSACHUSET B
I BUILDING DEPARTMEINT
120 WASHLNGTON STREET, 3a°FLOOR
TEL (978) 745-9595
F.-.X(978) 740-9846
KIMBERL.EY DRISCOLL
A-MR THOMAs ST.PIERM
DIRECTOR OF PUBLIC PROPERTY/BUILDhG CO\RRSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information - — Please Print t e ibly
Nalne(IlusilmssOrganiratinm'Individual): �✓lv L1/0'��5 /�C�� Q/V
Address: /' zr/L��f2i rr
City/State/Zip:Eblew��� Phone #:
Are ((al an employer°Check the appropriate box: 'type of project(required):
I.[}r/I am a employer with 4• ❑ 1 am a general contractor and 1
tntpinyees(full and/or part-time).* have hired the sub-contractors 6. ❑New conswsaion
2.❑ I canna sole proprietor or partner• listed on the attached sheet.t 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
INo workers'camp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. (No workers' sump. C. 152, gl(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers'
curnp. insurance required.) 13.❑ Other
-Any applicant out elmcks box 91 most also nil on the scctian below showing thcir wodctr'cumpensatiun policy inl4 matiun.
'i lomeuwners who when Ihir affidavit indicating'hey art doing all work and then hire outride contncton met mhmil a new aRWavit indicating such.
$\onm nors Ihul chcck Ihir box most anachod an sddiliurul Aux showing Ile none of the rub.eomncWn and Iheit worsen'comp.policy information.
I ant an employer that is providing Ivorkers'contpeusadon insurance for my employees. Below Is floe policy and fob site
information.
Insurance Company .Name: ` '�./, 'W/•( �@ ��� �/. d
Policy 4 or Self-ins. Lic. 0: I�tXN �O^C' S�G Q�Z� Expiration Date:
Job Site Address: /6 �� y ('� 7f City/Stale/Zip:
Attach a copy of the worhen'compensutloo policy declaration page(showing the policy number and expiration date).
I•uilure to secure coverage as required under Section 25A ot'h(GL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500,00 and/or one-year imprisonmcn4 as well as civil penalties in the form of a STOP WORK ORDER and aline
aF up to S230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Invtsligwions ol'Ihc DIA for insurance coverage verilicatiun.
I do hereby verrif under the pains and penalties of perjury that the infurrnutiou provided a/b/,/eve-iw}true nJ correct
gn. l rt' UnW: �(�
4,7
P o A: /
Of,fvial use only. Donor write in this area, to be conrpleted by city or tolvn official
City ne fmvn: Permit/I.lcense At
Iasuing Aulburity(circle one):
1. Board of Ilealth 2. Building Ucpartmcia i.Cityfrawu Clerk 4. Electrical Inspector 5. 1'Iunlbing 111,peelor
6.Other
Contact Person: Phone tt:_ _- _ __
.,�. CITY OF S:u.E„I, ttiL1SS:ICHUSETIS
BU9-DLNG DEP.kRl-%MNT
# t 120 WASHLYGTON STREET, 3'4 FLOOR
"I�EL. (978) 745--9595
F.ux(978) 740-90 4S
(<11tBERI.EY DRISCOIl.
P�UYO,'t THOSLi4 ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CONWISSIONEA
Construction Debris Disposal At'tidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CNIR section 111.5
Debris, curd the provisions of tb(GL c 40, S 54;
Building Permit 10 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 i'vIGL c
l 1 I, S 150A.
The debris will be transported by:
(name ufhauia) '
The debris will be disposed or in
(name of tactlity)
—_---(aJdress of facility)
I
siquature of pa'mif applicant --
d.rtc
`.
NOTES J
4RECEIP.T� � %N:��
I DAT/E��^ 1 0435658
s
RECEIVED,FROM + ��S�'S1r2..1> CT Or.1 a1`1�,
w, r UDR SSA C7�3 � jIZ\I NJ6" L S
"`"ti" FOR' ��,� .,- SG"A17ik: . . , ��ts�,��t�.- ``✓����'1.4.'�'d^.Nt'?3 'n1Vlti.r�+.'.�'
q r, w..�.
t ro ACCOUNT _ HOW PAID �+- ' . 1'."t r wt.V"✓nr
n ,'AMT.OF r} ,'S!," ■ ?{ b' r �} �',�^
'ACCOUNT f
�. �`� tCASH � �r YA`5i�e�✓` Yh.~ �J..y�1i!/r.Y✓l�.�w,tiW,��
♦ AMT. Y vnv
CHECK ^t �/r� %�� ��a ♦ f�n�''4 d4� wyt�4iy�j. / �➢'.`�/ �'
xp , ' BALANCE MONEY
'✓.� DUE. ORDER
a17
of the policy,_certain policies may require art endorsement. A statement an ibis&rtlfl a[e does not Confer-rights to'he cerGRcaze holder in lieu of such sndorsemenis(s)
PRuouc�ri _ TL --�Apple t Wyman Choice Eusines, Lent
1i" I 'Dila tStreet
Deve,1:,ALA: 0191 _�---- --- ---- -
-
INSURERSAFFORDINGCOVERAGE _� NAIC3
INSLREo n Atlantie Chatte:'`nsurance CcmnRn}_':'D.4C__ - d4:=b —
I —
DiTtT he -krevali:
III 1 L[Il<P Street
ETEwat fA. 62149
COVERAGES: CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURAIICE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N=PIED ABOVE FOR THE PC'ICY?-c RIOD
INDICATED. NOTWITHSTANDING ANY REOL'IREMENT.TERM OR CONDITION OP ANY CONTRACT OR OTHER OOCUTAENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR f.,AY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES 02SCRIBED HEREIN IS SUBJECT TO ALL THE Tc-Rh13.
SX CLUSIONS AND CONDITIONS OF EUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE _ I ADOL SUER POLICY NUMBER i POLICY EFFECTIVE POLICY EXPIRATION `LIMITS
In'Snh ._.__._—.. INS" MID DA iE(R0.4'LDIYY? DA TE(AIFdIDD,YYi ltn Tho.s.j
GENERAL LIABIL TY
T —
_
1 I _
L,i;T _—
iE
4 �N,
,UNSRELLA tCCV� -- II"-_—_--_•.—_.— ____�__ — � 'i iE✓JRrtEFi:E �._
BILITY ❑ r._---- �_ ___ - -
NlOLOI T' PISLITY ONAND :Z C�.GG:?,TSGOJ G9;GSr_'01? GDiGh,N�Gl-- ` -
EFIFL ~CR RBILITY
�—
I Lx,n r -L � TI
EL? Policy Coverage State:MA 100,000
The Workers'compensation policy does not provide coverage for Douglas Arevai I. tl----
IC �_ e.�L_ _ 100,000
OTHER u I��❑ _.
DESCR!FTION OF OPE"TIONE'LOC.ATIONSNEMCLES ie+,cif q.ORD IDt.AdaM1lon3i Remarks 5c::eaule,if maw splice b regWretl)
Attention: Please note that the Insured has not elected coverage for themselves and there is no payroll covered on this polio)'.
GEP71F4rAlEHOLDER -� s - y CANCELLATION -
,. - __ - •'ter - � _R r i L c _ rn
EXPIRATION DA ETHER �F THE IS JII G CO f PA^1'MILL ENDEAVOR TO MA L
AC
L1,.' Fuller Street BUT FAILURE TO DO SO SHAI L OAPOSE NO OELIGATION OR LIABILITY
Eveett .+IA 0211
T OF ANY KIND UPON THE INSURER_ ITS AGENTS OR R-F
PRESENTATIVES.
'- UTHC•RI2ED RCPRESENiATIVE
f[ �-
J-jys%e
ACORO 26 l2009109) !
CERTIFICATE HOLDER COPY >t9aecoa;ACDFD CO?.POFTTIO N. All rights rocarvee,
t1 Massa -Department of Public Safety ;r••-
r{ Board of Building Regulations and Standards,
(.� Construction Supen isor
III License: CS-087797 `
DOUGLASSAREVALO '
50Fuller. I;,}
EVERETTMA tr3U9A, ,r ..a. .."a
i
�,,(.r,. 2
" "' �� Expiration.,
Commissioner 10/29/2015
ft
4� L o � ��yy y ♦ k} ' '..
Oflice f Consumer Affairs&Business Regulati0p
,OMEIMPROVEMENTCONTRACTOR
,d egistration 138301 "' '"TYPE
' Expiration 92 i 3/101.5 DBA I
•e`I
s DSC PAINTING AND CONSTRUCTION 2
i
"DOUGLASAREVALO'^
i50 FULLER ST.
R EVERETT,MA 02149- " '*. ..'.. Undersecretary
ds+e ti4."F ,t I.YJ
Dsccacastro@aol.com
617 5921561 fax 6173816997
Address : M .? v/,"l
a
Home owner: Kelly Mcneil
Home owner address
Work description
Replace kitchen cabinets
Install vinyl floor
Replace lights fixtures
Complete paint
The cost of this project is $ 7,525.00
Any questios cal at 617 5921561
e7
GC Douglas Arevalo
Home owner acceptance contract
—acceptance
I