28 LEAVITT ST - BUILDING INSPECTION (2) Cr-z-7 3�
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standar RECEIVE M
Massachusetts State Building Code, 780 C SPECTIO'NAL E� VA
ertse or 2011
Building Permit Application To Construct,Repair,Renovate QIgDQlii ha
One- or Two-Family Dwelling jjf�jj CCIr' b- 08
This Section For Officigl Use Only
Building Permit Number: Dat pplied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 P
O per Address: ( e 1.2 Assessors Map&Parcel Numbers
I.I a 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(ft)
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:
Zone: _ Outside Flood Zone?
Public 2( Private El Zone:
if yes0 Municipal B On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne;of Record:
7?Au/D .+�1,&MAPe) Sl9LEH HA Q/y ?O
Name(Print) City,State,ZIP
' LEAY/ TT. ST q?� qD•49S
No.and Street - Telephone ;4"TtEddress
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building G1,11 Owner-Occupie Repairs(s) e I Alteration(s) 21 Addition ❑
Demolition d Accessory Bldg.❑ 1 Number of UnAlu I Other ❑ Specify:
Brief Description of Proposed Work 2: GLR 'LX 2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials) Official Use Only
I.Building $ l O, Soo — I. Building Permit Fee: $ Indicate how fee is determined:
)d 2.Electrical $ I -2- O V — ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
0. 3.Plumbing $ $OO, 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Su ression
Check No. Check Amount: Cash Amount
6.Total Project Cost: $ '� ❑Paid in Full ❑ Outstanding Balance Due:
'S-rr .t -r W .
st�iv s H r�m2c�c t� c I z S
"Ai.O h
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License f(CSL) 5 tc,� q 4
" �b
V ,,0.'�w e—` `�Q ' 'tea\ r) License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masom-y
RC Ranting Covet in
WS Window and Siding
SF Solid Fuel Burning Appliances
qa 1 Insulation
Telephone Email address D Demolition
5.2 Registered HomeImprovement Contractor(HIC) 13 $ '9 xE 2
Z
' 7 e' ro\ N ��A? 7 �LZ�''a HIC Registration Number Expiration Date
HIC Conn any Name or HIC Registrant N me
ei�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 M.-N N O.IL,` .SR fN
to act on my behalf,in all matters relative to work ized by this building permit application.
Print Owner's Name(Electronic Signa(re) 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 accu he best oft cnowledge and understanding.
Print Owner's or Authorized Agent's Na El iam gnre) 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eovdus
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"
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
a - OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistrabon 133842 Type: Office of Consumer Affairs and Business Regulation
'Expiration 6/17/2015 DBA 10 Park Plaza-Suite 5170
Boston,MA 02116
ESPINOLA CONSRTUCTION;&REMODELING
MANUEL ESPINOLA , {
7 SHAMROCK ST. / /J
PEABODY,MA 01960 (��J//J,�L9 ..�.a-i�y'y�e'C,� .
Undersecretary Not valid withoutithout A
1 Massachusetts -Department of Public SaiMty
-Board of Bur{+ing Regulations zn.d Stanch, 15 a
.' C,nnsttuchzxn Snpi n'r+nr
a
License: CS-079956
MANUEL S ESPINOLA
7 SHAMROCK ST If e x
PEABODY MA 01960
r-
�J "Pi ration
Lommiss oner _ 12/07/201,0,
i
CITY OF SiUENI, NL' SSACHUSETtS
BUILDING DEPAR-I'NIE.`iT
120 WASHINGTON STREET, 3'a FLOOR
\'. T EL (978) 745-9595
F.'a(978) 7404846
KI\iBERLF-Y DRISCOLL
'tiL1YOR T Homs ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Alt tliennt Information Please Print LeLyibly
.Name lllusinessOrganiratinn,'Individuall /����iv ��` A \ �-���- 1�--+rg c�
City/State/Zip: `c�n�T� V\r.A Phone It:_ i 'ai- % 2
Arc you on employer:'Check the appropriate box:
'Type of protect(required):
1.0 I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
��'�nplci(full and/or part-time).• have hired the subcontractors
2.3 I am a sole proprietor or partner• listed on the attached sheet. t 7. remodeling
ship and have no employees These sub-contractors have 8. C] Demolition
working lot me in any capacity, workers'crimp. insurance. 9, Building addition
INo worker•'comp. insurance 5. 0 We are a corporation mid its
required.) officers have exercised their 10.0 Electrical ropairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.[No workers'comp. C. 152, §1(4),and we have no 12.[1 Roof repairs
insurance required) t employees. [No workers'
cmnp. insurance required.) 13•Q Other
-Arty upplirun our checks bux 01 must also fill uul the section below showing their workan'cumpeniedom policy intilrmodon.
'I b+m¢uwncn who whmil this aln(lnvit indicmins they are doing all work and then hire outside camncim miul mthmit a new arndavil indicating such
<'nmrxtun Thal chsek this box mtnl4nachd an %Witiuml:heut showing the nunu ahhe mbtenlnclun and'half woken'comp.Polley information,
!unr an rurpluyer that is providing workers'conrpensadun itrrurunce jot my employers. Belo v is the polfcy and Job site
iufrar+uutinn.
Insurance Company Name:
Policy it or Self-im. Liu. th Expiration Date:
Job Sift Address: City/state/Zip;
A tfach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failuru to secure coverage as required under Section 25A of MGL c. 152 can toad to the imposition ofcrintinal•penalties of a
fine up to S1,500.00 und/or one-year imprisonment, as well as civil pcnahics in the form of a STOP WORK ORDER and a fine
of up to S-MAO a day against the violator. 13e advised that a copy of this.statement may be funvardcd to the Office of
Inecstigatiuns ul'Ihu MA for insurance coverage verification.
Ida hereby cerdfy under the pains wed prualdes of perl'ury th t th injunrrutlun pr vided ubwe fs true and correct.
ram. �(�J / �n, `la-
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Phone!' Q � �3D � l9 t-Lq 2— -'-
F
e wily. Oa nut write in dd.+'area, to be completed by city ur town gj1cfut
lvit: _ -- Permidl.leense tl
lhurify (circle one):
f ilealth 2. ❑uildlni; lieparfumot 1.Cilylfumn Clerk A. Electrical luspechlr 5. 111mul)iug Inspec❑rr
Wort; Phone lt: