23 IRVING ST - BUILDING INSPECTION The Commonwealth of Massachusetts
� OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 780 CMR SdMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This Sect' 'Fo;Official Usk Only
Building Permit Number. Date App r&
Building Official(Print Name) .'Sig Lure Date
SECTION 1: SITE INFORtMATION
1.1 Property Addre j �- 1.2 Assessors Map& Parcel Numbers
023 .v, 16, -. 0 - --7 6-(D
1.l a is this an accepted street?yes_ no Map Number Parcel Number
—
1. 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
1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public> Private❑ Zone: _ Outside Flood 7,one? Municipal YOn site disposal system ❑
Check if yes
SECTION2; PROPERTY OWNERSHIP
2.1 wnertofRecord: y
(ter iubl Se.le.v, NYC-c�t ���
Name(Print) City,State,ZIP
3 cwU Ate{.._ `J)k 853 6I/V
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply),
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition Er Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
[tern Estimated Costs: Official Use Only .,
Labor and Materials
I. Building Building Permit Fee S frtdicafe how fee is determined:
�. Electrical j ❑ Standard.City/['own,Application Fee.
❑Total Project Costa (Item 6)x multiplier x
3. Plumbing S 2. dtherFees: $
t. Mechanical (IIVAQ S List:- -
5. Mechanical (Fira $
Suppression) _ Total All Fees: .S
Check No. __Check Amount: Cash Amount
I'nhtl Project Coif S
I 0 Paid in Full C Outstanding Balance Due:
O` 5
_ r '
SECTION 5: CONS'rRUCI'ION SERVICES
5.1 C nshvctionSupervisorLicense(CSL) C$-k Z7�/ Z i
1 �J
h )4 err Na License Number Expiration Date
N;une of CSL l told r
I / List CSL Type(set below)
b f(2 "VA- rt� 'i. Description
No. and Street
��n U Unrestricted Duildin s u to 3i,000 cu. ft.)
R Restricted 18c2 Family Dwellin
Cayfrown, State, ' DP M Masonr
RC Rootin,,Coverin
WS window and Sidi""
SF Solid Fuel Burning Appliances
.7Y1 _ //04-W I Insulation
Tole hone Email address D Demolition
5.2 Registered Horne Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or 111C Registrant Name
No.and Street Email address
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 .......... ❑ No...........-Er�
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 o 1 e in No
to act n my behalf, in all matters relative to work authoriz by this building permit application.
D S� � sZ 3zsi3
Prin w is Name(Eldc ronic Signature) Date
SECTION 7b: OWNEW 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.
I'n Owner's or Audtonzed:\gene's Name(Electronm 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 [bole Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under M.O.L. c. 142A. Other important information on the HIC Program can be found at
www.maes.,,uv oca Information on the Construction Supervisor License can be found at www.mass.ctw dL
2. 7%Whenubstantial work is planned, provide the information below:
Totaarea(sq. 11.) (including garage, tinished basement attics, decks or porch)
Grossvng area(sq. fi.) _ Habitable room count_
Number offiraplaccs_. Numberofbedrooms _ —----_--
Number of barhrooms Number of half baths _
[vpe of heating system Nunther of decks/porches
ftipe of cooling syctcm Enclosed Open _
S. "FotA Project S(Ju:uc Frnota"C" ntay be sub,tit itcd rk)l Vw d I'rujcct('ost'.
CITY OF &u.Em, i\tLu&S cHUSETTS
,. BU=ING❑EPAIMLEINT
120 WASHNGTON STREET, 3"FLOOR
' T EL (978)745-9595
Full:(973) 740-9844
KI.NfBERI.EY DRISCOLL
,1�j�YOR "ITlo+us ST.FtEalcf>:
DIRECCOR OF PUBLIC PROPERTY/BUILDmG COSNISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Ptumbers
Amilleant information / Please Print Legibly
VamelBusiituss.Ur�tnimtiurulndividuul): �O�p� �Gq leer.) O
Address:
City/State/Zip: O Phone#: 7 11 - T/Cd - L Y7
Arc you an employer?Check the appropriate boa: Typo of project(required):
1.[] I am a employer with 4. 0 1 Am a general contractor and 1
lnplayees(roll and/or Part-time).* have hirer)the subcontractoo 6. ❑Now construction
n
2.9 lain a sole proprietor or partner. listed on the attached.rheut It 7• ❑Remodeling
ship and have no employees These subcontractors have 8. effe molition
working far me In any capacity. workers'camp.insurance. y, 0 Building addition
(No workers'comp.insurance S. 0 We are a corporation and its
ruquirad.i officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,11(4),and we have no 12.0 Roof repairs
insuranearequired.) t employees.[No workers' l)(]Other
comp.insurance required.)
-,lny apPllc:ua thug Ouckabox Of must alm nil oul,hv tatiun bafow showidit their wahars'eompmsadun pulley inrurmallone
'I Nweuwmns who submit this a0ldsvit Indicating they are doing all work and then hire Militia contractor muss submit s mils antdavil indteating such.
:Conimuton that Omit This box must anachad an addillund shay showing old name of the mb eantracters and chair workars'camp.policy Intlo tnada*.
fain un eurpluyer that b provld/nX Ivorken'cotnprnrodon fnruranea�or my ernployearA Below/it floevolley anal Job site
injorarailon.
Insurance Company.Name:
Policy 4 or Sclf-i,u. Lic. 0: Expiration Date-
Job Site Address: City/Stateizip:
Attach a copy of the workers'compensation pulley deelaratlon page(showing the policy number and expiration data).
Failuw to wcuru coverage as required under Section 2JA o(YIGL a 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and it line
of up to$250.00 a day against the ' later. Ile advised that a copy of this stalcmunt may be furwurded to the Of iiea of
invcstigmima ul'tha DIA fur ins rat a covaraga varificatiun.
/Ju hereby rerl//y tre)Ji /rr p Ind wrJ nelolrr u/par/ary Jrut fAi Gr/Lnnurlan provlJad dbuve is true and correct.
ii-mirt re:_ bate. _�2, 2 3
iOl/iriu!use un!/t Do nut,wile in r/rlr urrq to bar rulupleted by city or town n/J7elat
City orTusvn: Pcranful.lcente,9
Issuin lullturil __......_.__._
a• y(c(rcia one):
1. Duard of Ifuallh 2. Iuilding Department .l.Citylfuwn Clerk 4. rfeetrical fospector 5. Ilumbing lnepeeror
6.Other
Contact I'ertnn: --- .... ._. Phono if:
I
f
"h �. . CITY OF SA1L.EM) NLUSACHUSETI'S
l3"ZL%G DEP.IRTNZNT
� y 170 NVASHLNGTOV STREET, 3" FLooR
\ * =� TEL (978) 745-9595
F.UX(978) 7-10-9346
U�[BE.IiLEY DRISCO[.L
ibUYOR Twnu ST.PtERRH
DumcroR OF PUBLIC PROPERTY/8I I-004G COSL\II5SIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of NMI. c 40, S 54;
Building Permit It 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 transportcd by:
��C9 rn nir+. P D 5 „Gy�
U (name ut hauls )
The debris will be disposed of in
_—wood tivaStr—
(name ort-acility)
(address of tacdjly)
;Irucc of permit applicant
3 -2s c3
date --
4d+1 r.l l d•:c
9 Massachusetts-Department of public Saferd
Board of Building Regulations and Standaras
Cnnvtrucnen Supen isor
License CS-o62744
. - - `�
JOSEPH LAUI
104R NORTJC-SMEET ,. .r
North Resdieg MA 01864 r
J
itl?�
Commissioner Expiration
0110=014