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25 JAPONICA ST - BUILDING INSPECTION (2)
12- $2- sy- y Conunonsvealth of Massachusetts Sheet (Metal Permit Dale: l2rc� Penoit 4 q 3 3 -I z Fslim:ded Job cost: .$ Permit — !\ �-` Pcc: S � <�U 1'I;111s Submiltcd: YES _ NO_ Plans Reviewed: YFS NO _ Business License 1) Applicant License M Business Intbrmation: Property pruner/Job Location Information: ' Name: Name: Street: Jn,P�a:9 � /y ye -�- ��(� c� Cityll'own: rd� ,i � � � �n \ City/Town: f Yy Telephone: t pce)�5'3 <c( � t7jq c/ �6 2-, �--� Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO J-I /D -(-unrestricted license scoot m,t J-2/M-2-restricted to dwellings 3-stories or less atld conu»ereial up to 10,000 sq. R./2-stories or less Rcsidentlal: 1-2 family_ Multi-family ,"/ Condo/Townhouses_ Other_ Commercial: Office Retail Industrial_ Educational_ Institutional Other_ Square Footage: under 10,000 sq. R.— over 10,000 sq. tt._ Number of Storlcs:._ Sheet metal work to he completed: New Work: Renovation: _ IIVAC_ Metal Water shed Roolin b— Kitchen Exhaust Syslcm_ 'Ictal01inotey/ Vents_ Air Balancing_ Provide detailed description of work to be done: 2;�Vsyc' �d /l /C 4Li I i INSURANCE COVERAGE: I have a current Ilabtlt Insurance policy or its equivalent which meets the requirements of M.G.L.Ch.i12 Yes No(] If you have checked Yes.Indicate the type of coverage by checking the appropriate box below: A liability Insurance policy Other type of Indemnity ❑ Bond req OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not have ation waives nce coverage equlremenluired by Chapter 112 of the Massachusetts General Laws„and that my signature on this permit application�3 Check One Only E L LC A Owner Agent ❑ Signature of Owner or Owner's Agent By I have submitted(or entered) ing plication are true and chocking log this box Z,l of my Nn wYedg and that certify that l of the details and Iall sheet metal work an Instsllatlons performed under dla perrnitdIssued lfor ghls application will be In compliance with all pertinent provislon of the Massachusetts Building Code and Chapter 112 0l the General laws. Duct Inspection required prior to insulation Installation: YES_NO Progress Inspections Date Comments Final luspection D:ltd Comments Type of License: By LJ Master q Line_ ❑blaster-Restricted �;iy:Ta•.rn�_____— oJourneyperson Signature of Licensee narina s._ []Journeyperson-Restricted License Number: roa 5Apo, Check at:•r'ry m.rss,gpvhiLInspd or Si i CITY OF S. .EN4 N'LkSSACHLSETTS • BUILDING DEPAM.CENT • ' 130 WASHINGTON STREET,r FLOOR TEL (978)745-9595 FAX(978)740-9846 KI.%IBERLEY DRISCOLL MAYOR THO&W ST.PiEaRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lei 1 Name(BusinesaOrganizadoNlndividual): — Address: / City/State/Zip:6&/'A -tf Phone Il: Are you an employer?Check the appropriate box: r6.Y pe of project(required): L❑ I am a employer with 4. ❑ 1 am a general contractor and 1 ❑New consrueuon employees(full and/or part-time).• have hired the sub-contractors 2.❑ i am a sole proprietor or partner- listed on the attached sheet t . ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity, workers'comp.insurance. g, ❑Building addition (No workers'comp. insurance S. ❑ We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees.(No workers' l3❑Odta comp.insurance required.] •Any applicant char docks box cal must also all Out the section below showing their workers'compe pion policy infu radon. I htmeowtsus who submit this affidavit indicating they ar doing all work and then hire outside contraction must subunit a new affidavit irdicali ig such. :Contmeton that chock this bon most attached an additional sheet showing the nmoe of the sub•Pomractors and their worker'comp,policy information, I am an employer that Is providing workers'compensatlon Insurance for my employees Below Is the policy and Job cite information. Insurance Company Name: �,t r-7 Policy#or Self-ins.Lic.#: q Y v G C �l / (2(--4-Expiration Date: / 0/ ' Job Site Address: 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 23A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 S230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Invesligalions of the DIA for insurance coverage verification. I do hereby certify under Cite pains and penalties of perjury that the Information provided above is true and correct, Sidnantra• Dnte Phone#: OJjciai use only. Do not write in this area,to be completed by city at town afrciaL City or Town: PermitfLicense# Issuing Authority(circle one): 1.Board of liealth 2.Building Department 3.Cilyirown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: _ i3fY�AYTi3'OF rYrx -SAGHtlSt4TS - Stir'_ET Iv1ETAL. bvt)RKERS AS A MASTER-UNRESTRICTED ISSUES THE ASOMLICENSE TO: h IAN PALEN 1L. JUNEBUG LNG^ f' X N DAN% IL LE NH °03819-3238 170 04/28/L4 1717— Fold,Then Detach AIonB AM Perforations Relrirrtnt Tr.zftrJ n eytd I Ccrtiilento a:G: "� 4, ACM rm.r.c ,— has,been certified as I+UNIVERSITI'# wT.. technician as require ¢by t 't 40 CFR Part B2, Sub�Art F -a, �05p o w _ 4d- Hgtc 65 iQ . . 04PNB67031 t 3.DOB: 04/03/1967 18.Eye: BLIJ 4b.Exp: 04/03/2018 19.Hair:BILK [ 15:Sex: M ?.BRIAN J PALEN _ f �- ✓#.12 JUNEBUG LN �• wr'O q J _ l L '52zz 1 ,3 zu The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR S Revised dMar Mar 201/ Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied, u�F Building Official(Pri Name) Si ture Date SECTION 1:SITE INF0914ATION 1.1 Pro erty Address•/U 1.2 Assessors Map&Parcel Numbers L-I�VSN 9 1.1a 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(fit) .....�, 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 wner'of Recgqrd: wo._' z M 10&t r . 5 y� 0-7 4 CV 6 2 C Name(Print) City,State,ZIP l ,Q(�>N 3 No.and Street I'elep one 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 ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work : 11 G {/ v, Af-ef rIA ejlls L?)1� 4551 /D✓�S SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1. Building 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ ro e566 2. Other Fees: $ �f� 4.Mechanical (ffVAC) $ List: ( ! 5.Mechanical (Fire $ Total All Fees:$ Supression Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 30 Ct(a0 r ❑Paid in Full ❑Outstanding Balance Due: ' LU �t7Wr�� SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �+/ oo© mqo �a / #/y _J_ y License Number Expi tion ate Name of CSL Holder List CSL Type(see below) V Type Description No.and Street s �/ O U Unrestricted(Buildings u to 35,000 cu.ft. Restricted 1&2 Family Dwelling City/Town,Stag^ ZIP M Masonry RC Roofing Covering WS Window and Siding p� �+ SF Solid Fuel Burning Appliances �l��cS��ypo �Ly -�Cl ��C(.t^� I Insulation Telephone Email address D Demolition 5.2 Registered Home improvement Contractor(HIC) . I/0 l412ff d zo ! /IZiNI HIC Registration Number xpir tion Date HI Comp Name or HIC Rego r ame I y TY/</ Y�J_ �t.Z No.and Street W5VY � ress �1 (l 8�� Email a CiYy/ ownl 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 ..........01 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 329 9 k M k 01tY to act on my behalf,in all matters relative to work authorized by this building permit application. Q• 10e1W &4M_ oIA- powev`S t7 -/3 Print Owner's Name(Electronic 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 con in in thi app licatipp is true and accurate to the best of my knowledge and understanding. olfil/ /"e zo 3 Pri [ wner's o u orize ge t s Name(Electronic Signature) ate NOTES: l. 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. og v/oca Information on the Construction Supervisor License can be found at www.massgov/dps 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" aCITY OF &UEN111, iNLkSSACHUSETTS BUILDING DEPARTIffiNT 120 WASHINGTON STREET, 3'm FLoolt TES.. (978) 745-9595 Fin(978) 740-9846 KINtBERi EY DRISCOLL MAYORTHOblAS$T.PIERR& DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLUiSSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information I' , Please Print Leeibly Name (tlusin, s&Organization/Individual): ICN.`Ik Ct9y2L�,4 Address: (, w-fl" r' j City/State/Zip: - I tJ JJ L4 Phone #: 7 r/ �fT(�r t/8-;'7 Are you an employer?Check the appropriate box: Type of project(required): 1.® 1 am a employer with 0 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ t am a sole proprietor or partner- listed on the attached sheet.: T HRemodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition [No workers comp. insurance 5. ❑ We are a corporation and its require].] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself. [No workers' comp. C. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] `Anv applicant that checks box#t most also fill out the section below showing their workers'compensation policy information. 1 I11w,,owmw who submit this affidavit indicating they are doing all work and then,hits outside contractors most submit a new,al'fidavil indicating such. =C maracton that check this box most attached an additional sheet showing the name of the sub�coatmctora and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance jar my employees. Below is the policy and Jab site information. qr Insurance Company Name:— � &V `✓1/4 C Policy#or Self-ins. Lie. #: W C, a rp S .3'77 Y61r, 0/ Expiration Date: IVIA711Z Job Site Address: l 0oIsS7Y& rf-Ir— City/State/Zip: 54toffw 1414- afVV 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 S 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 S250.00 a Jay against the violator. lie advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c rtrfy corder the pains a pen ties of perjury that the information provided above is true and correct Si zn a ore Date: oLr7 l3 Phone#: Official use only. Do trot write in this area,to be completed by city or Iowa oJrciaL City or'rown: Permit/I.lcense Issuing Authority(circle one): 1. Board of health 2. Building Department 3.Cilyffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.01her Contact Person: Phone#: i CITY OF S.-1I.E:NI, TAksSACHUSEM BUILDIING DEPARTNI[EINT • 130 WASHLIIGTON STREET,3"'FLOOR T'FL (978)745-9595 FAX(978) 740-9846 KI%IBERLEY DRISCOLL MAYOR THoatAs ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUILDIING CONDIISSIONER 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 11 L5 Debris, and the provisions of MGL c 40, S 54; Building Permit# 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 transported by: (name of hauler) �— The debris will be disposed of in : (name of facility) &4 (address of facility) signatur permit ap i ant [e Jcbrisatr,dce