28 JACKSON ST - BUILDING INSPECTION $ G(C 3Ll 38 33
1 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 Divelling
This Section For Official Use Only
' ^ Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION _
1.1 Pro er�t ,Addr s: y�— 1.2 Assessors Map&Parcel Numbers
_��p(/ VC SOV 5 .
•++ m
1.1 a Is this an accepted street?yes no Map Number Parcel Number v �,�
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District__ Proposed Use Lot Area(sq ft) Frontage(it) M c22
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard CP in
Required Provided Required Provided Required Pr �ded
1.6 Waser Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public u1u Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ner of Record:
a9 � 110,0E
Name(Print) // �— City, State,ZIP
Or.40 Boh sf /97F•3F7-/7ry
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ±NumberLf
wner-Occupied ElRepairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Units_ Other, ❑ Specify:
Brief Description of Proposed Work': O /rJS - New R02t t31COV/P5ON. f4lect#q
I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ �,j t7d U.�� 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g �CIV ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing O, r 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
`/ Check No. Check Amount: Cash Amount:
6. Total Project Cost: $A7 6JO ❑Paid in Full ❑Outstanding Balance Due:
1�f Massachusetts - Department of Public Safety
�f Board of Building Regulations and Standards
Comtrutnu❑ Super,isor
License. CS-028073
EDWARDJPHFkAN
931 TURNPIKE ST I x. _
N ANDOVER MA 04V
nI, `" Expiration
commissioner
03/2012016+
CUM ONWEi H OF MASSACHUSETT—TS
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PLUMBERS ;A DASFITTERS
i -r ISSUES THEuFOLLOWING -LICENSE
REGISTERED AS A PLUMBING CORP ;
EDWARD J PHELAN
��3lpAWDOVER.'{kECHANICAL CONT; I"NC,M .,
NDRTH ANDOVER MA 01845 6107
2146 2 ;
r 6MM6Nw9ALTH OF MASSAC USETT&,t
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PLUMBERS-AND"'GASF I TTERS
'ISSUES THUFOLLOWING L+CENSER
IIGENSEE AS A'MASTER PLUMBER
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SECTION 5: CONSTRUCTION SERVICES
J 5.1 Construction Supervisor License(CSL) � S U Z &07-5
f—t /om/ I`yj J �h 2,o License Number Expiration Date
Name of CSL Holder
p 3 t •7-` r / fit.� List CSL Type(see below)
No.\and Street / Lc. J Type - Description
V U �1 Unrestricted(Buildings up to 35,000 cu.ft.
6 1 K w'P'y #4 L � 1 R Restricted l&2 Family Dwelling
City/Town,grate,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/� 22 SF Solid Fuel Burning Appliances
g 7�G a! ` /6 J I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC 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........... ❑
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electror66 Signature) 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 this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized nt's Name(Electronic Signature) 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.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dl)s
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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
? -
r,� Office of Investigations
600 Washington Street
Boston, MA 02111
"z>="•=<'` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/lndividual): lq✓'G /k u r tm._'c/`
Address: G 7 C- tvve-v J�
City/State/Zip: I- Vajt � V14>- 0, 1-5(f Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.® I am a employer with 8— 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 sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
workingfor me in any capacity. employees and have workers' 9 y p ty ❑ Building addition
[No workers' comp. insurance comp. insurance.#
required.]
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]f c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. /� r_ p
Insurance Company Name: f"T
Policy#or Self-ins.Lic.a#: 1d-.1(G ^b�j0 cO 4 9 O 1 72 114 Expiration Date: Z/
Job Site Address: o \I �T J 11 n/ J—City/State/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 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 yerification.
I do hereby cerllifv un r t e pain en ' s of perjury that the information provided above is true and correct.
Si nature: C Date:
Phone#: 7
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4,Electrical Inspector 5,Plumbing Inspector
6, Other
Contact Person: Phone#: