10 LEVAL RD - BUILDING INSPECTION (3) k
The Commonwealth of Massachusetts fNSPECT�ON S CITY OF
� Board of Building Regulations and Standards
IY1 % Massachusetts State Building Code, 780 CMR ^S1E1I�
1DI5 A 2 ReoReryt(fur 1011
(� Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divellhkg
This Section For offtc I Use Only -
Building Permit Number: Do Applied:
V ' building Otlicial(Print Name). SignatureDate
lSECTION 1:SITE INFORMATION`
r(� LI Property Address: /0 4fU4L R 1.2 Assessors Map&Parcel Numbers
L I n 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 11) Frontage(11)
1.5 Building Setbacks(R)
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2: PROPERTY OWNERSHIP)'
2.1 Ownerr or Record' ��
me(Print) City,State;ZiP
A)/fa//,4, RD. _ 97R:59y 8?66
Nu.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.O Number of Units_ Other Specify: !/IFArrIfRl7fJTi0N
Brief Description of Proposed Work':
-TnJ1'U[ATb d777C d- EXTERIOR WALZS' / Irr/1 arNiL•r nt/1tdQif //Uft1lR-T/0/�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ °a I. 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 $ 'Pother Fees: $
4.Mechanical (FIVAC) $ List,
5. Mechanical (Fire ,S Total A[I Fees:Si--
suppression)
Check No._Check Amount; Cash Amount:_
6. Total Project Cust: 00 ❑Paid in Full ❑Outstanding Balance Due:
Ste ( z ��
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS'166759 �/-3/-/77
Aab License Number Expiration Dale
Namc of CSL holder (/
List CSL'fype(see below)
5 Type Description
No.:md Street
U Unrestricted(Buildings tip-to 35,000 w. tl.
lll0l flub W R Restricted l&2 Family Dwelling
Cily/'1'own,State,ZIP �M Masonry
RC RoofingCovering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
'Tole hone Email address U Demolition
5.2 Registered Home Improvement Contractor(HIC) //�"SQS D- A-/
�Tr/Y•A CQjt Al CO HIC Registration Number Expiration Date
HIC Company Nanc or HIC Registrant Name
i , reLr 677pd1 ST
No.and Street Email address
mA-�o,��tA. oaiyB 61�S9a-6�19
Cie /Town State ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L c. 1152,g 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 IsSua ce of the building permit.
Signed Affidavit Attached? Yes .......... No........... O
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 /)1L'&&4 A S71er4
t9 a my behalf,i all matters relative to work authorized by this building permit application.
� D
Print Owner's Nmne(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,)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.
/yl.4��o/� _/�i�lN R S7iccA l 1ti-/s
Print Owner's or Authorized Agent'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 nor have access to the arbitration
program or guaranty fund under I.G.L.c. 1 q2A.Other important information on the HIC Program can be found at
eww.mass. ov'oca In Formation on the Construction Supervisor License can be found at cvww.nnass.•ov:'dus
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) '!1 ,(including garage, finished basement/attics,decks or porch)
Gross living area(sq. II.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
"type of heating system Number of decks/porches
'fypeofcoolingsystem Enclosed Open_
1. 'Total Project Square Footage"unay be substituted I'ar'•'fotat Project Cost'
The Commonwealth of Massachusetts
l Department of Industrial Accidents
Office oflnvestigations .
600 Washington Street
Boston,MA 02111
UT www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anmlicant Information Please Print LiZiblV
Natrie(Busineu/Organization/lndividual): 51?&A
Address: 171, 1"f&&r7VAI ,-T
City/State/zip: MLAJ4 M. 4gL/A Phone#: !/1-_f92- all
Are ou an employer? Check the appropriate box: Type of project(required):
1.21 am a employer with_a 4. ❑ I am a general contractor and 1 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.t �• Remodeling
ship and have no employees . These sub-contractors have a. ❑Demolition
working forme in any capacity. workers'comp.insurance. g. ❑Building addition
_ [No workers' comp.insurance 5. ❑ We are a corporation and its
requited) officers have exercised their 10.Q Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption'per MGL 11.Q Plumbing repairs or additions
myself.[No workers'comp. a 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers' 13.❑Other
camp.insurance required.)
•Any applicantthat checks box a]mostalso fill•out tht section below showing their worYers'mmpeandon policy information.
t Homeowners wbo submit this affidavit indicating they are doing all work and then hie outside eontnetim mostsubmit a om affidavit indicatbg such.
tContraetors that check this box most attached in additional sheet showing the name of the sub�tnc0crs and then workers'tramp-policy information.
lam an employer that is providing workers'compensation insurance for my•employees. Below it the policy and job site
information
Insurance Company Narine: ZyAiu/ A/lIE e-Al —
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: /Q ZZLI L 9b. City/State/Zip: Sl�� (0,4.
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 e. 152 can lead to the imposition of crimutal penalties of a
fine up to$1�500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250A0 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certify under theepains and penalties ofperjury that the£information provided above is true and correct
Signature: Date: /'14-/S
Phalle*
Official use only. Do not write in this area,to be completed by city or town 0.elcial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
`' CERTIFICATE OF LIABIUTY INSURANCE DATEiRjfiRM YYYY1
T. l ATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERITFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS,CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
OR FiRODUCER.AND THE CERTIFICATE111OLDEW
IMPORTANT:Ifthe Certificate holder Is an ADDITIONAL INSURED,the poilrA es)must be aiulorsed. N SUBROGATION IS WAIVED,subject to the
terms and condBlons of the policy,certain pollcks may require and endorsement. A statement on this catmcate does not confer rights to the
Certificate holder in lieu of such an s
PRODUCER CONTACT
NAME:
EASTERN INS GROUP LLC PHONE FAX
233 WEST CENTRAL STREET (NO,Mo.EXw- (AC,NO)'
E4YUL
NATICK,MA 0176D-3757 ADDRESS:
22LRD INSURER($)AFFORDING COVERAGE NAIC0 li
NSURED INSURER A: AMERWANZURICRINSURAHCSCOMPANY
STICCA,MICHAE.A DBA STICCA CONTRACIINO It�aNER B.
INSURER C:
INSURER D:
376 WASHINOTON ST INSURER E:
MAIDEN,MA 02148 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
NSIMW ABOVEFORTM N T M
MY REQUI EMUMTERM OR CONDIrgN OF MY CMRRACT MI OTHER DOCUMBEr WITH RESPECT TO Vnt*ITHS CBITIRCATEMAY aE ISSUED OR MAY PENTANWTHE*R=R�MANCE
AFFORD BYTMPOLRSEBDEBCMMMMMBMSJWfTOALLT/ETOMEK=MMBMDWWMDHSOFTAIOIPOLIML LYRESNYWNMAYHAYEBF81R®1JC®BY
PAID CLAM
am ADD POLIOYHF'DATE POUCYEXP?L1XrT('Ea
LTR TYPE OF NNIRMCE L R P'OLIC7 NIAIDFJt PBaDO,YYYYI pOaDD1WLAWS
GENERAL LIABILITY CCURRENCE y
COMMERCIAL GENERAL LIABILITY E TO RENTED $
CLANS MADE Q OCCUR. ES(EaP(AIry wle IcersdR) SNAI B ADV NIURYGEM.AGGREGATE LIMIT APPLIES PER: AL AGGREGATE S
71 POLICY aPROJECT�LOC CTS-COMPAW AGG S
AUTOMOBILE LIABILITY NED SINGLE S
ANY AUTO (ES aCCiderd)
ALL OWNED AUTOS Y eJJURYS
SCHEDULEAUTOS e�^)HIRED AUTOS �RY S
NON-OWNED AUTOS ERTY DAMAGE S
adw)
UMBRELLA LIAR OCCUR EACH OCCURRENCE $IXCESS UAS CLAIMS-MADE kGGREGATE S
s
DEDUCTIBLE
S
RETf]YTIDN S
A WORKERS COMPENSATION AND WCBTAIUTORY OTHER
EMPLOYER'S LIABILITY YINUS-2E248586-14 OSMSM14 OflrO57015 � UMRS
ANY PROPERITORIPARNEWEXECUTIVE N/A ELEACH ACCIDENT S 500,000
OFFICEWMHABER EXCLUDED?
(rmddmrti 101) E.L.DISEASE-EA EMPLOYEE $ 500.000
N Yet.desabe UMR E.L.DISEASE-POLICY LQAR IS 500,000
DESCRIPTION OF OPERATONS I
DESCRIPTION OF DPERATONSILOCATIOiSMQOCLEA RESTRIOnONSISPECIAL ITEMS
T HIS REPLACES ANY PRIOR CERTIFICATE WU®TO THE CER71RCAI11ROLDER AFtHCIING WORKERS COMP COVERA06
771E WORII M'COMPSMA710N POLICY DOES NOT PROVIDE COVERAGE FOR SITCCA,MICHAEL A.
CERTIFICATE HOLDER CANCELLATION
CAPIC INC SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,HOME WILL BE DELIVERED
100 EV EREIT AVE UNIT 14 N ACCORDANCE VKIN THE POLICY PROVISIONS-
AUTHORIZED REPR ".: . .: ..
�r
CHELSEA.MA 02150 J�....
ACORO 2R(20101M The ACORD meals and logo are regismred marks of ACORD 1969-2010 ACORD CORPORATION. All rights reserved.
Comtruction Sapen'iwr''
_ >= CS-106M
BRADL EY DANOFF
IS MARION ROAD
wallaeftew MA 01880
�•�•-.�.de 0113112017
Unrestricted-Buildings of any use group which
Comoro lewthan 35,000culm fat("Im)of
enclosed space. -
Failure to possess a anent edition of the Massachusetts
State Buildirw Code is cause for revocation of this license.
ForM ioaminalnfarmaaonvisit w .Mass.Gov/M
td 2Of of Consumer Affair and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement-.Contractor Registration
Registration: 110505
Type: Supplement Card
U Expiration: 10/20/2016
STICCA CONTRACTING CO
BRADLEY DANOFF ri -
376 WASHINGTON ST -
MALDEN, MA 02148
w.N Wit" Update Address and return card.Mark reason for change.
SCA1 0 20M-05/11 Address ❑ Renewai3O Employment Lost Card
(O(�ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only
- OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration: 10605 Type: 10 Park Plaza-Suite 5170
Expiration.. 10/20/2616 Supplement Card Boston,MA 02116
STICCACONTRACTING�CO �'`�
y
BRADLEY DANOFF.`
• 376 WASHINGTON ST'a `-
MALDEN,MA 02148 Undersecretary Not valid without signature