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11-13 LIBERTY HILL AVE - BUILDING INSPECTION (3) r u The Commonwealth of Massachusetts \ F Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, 71" edition OF SALEM Revised January (� Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008 f7V�sljl.J, One-or Two-Family Dwelling This Section For Official Use Only Building Permit Mbbeer: Date Applied:Signature: `/i`6�rt7 9 d!� 10 Building Commissioner/Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers l.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information- 1.4 Property Dimensions: Zoning Disnict Proposed Use Lot Area(sq fu 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' Owner of Record.. '5 lSC3 yLv� J9 �� I f, (� L.lb" �11� 5�i1 —, Address forSeivice .Signature u Velephone-I SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: BSfDesc�ription fPropose1l Work 2: t ;at SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1. Building $ faj�,60 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 $ 2. Other Fees: $ 3 4. Mechanical (HVAC) $ List: ,. 5. Mechanical (Fire $ Suppression) Total All Fees: $ � Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 9,SV/.,V'00 ❑Paid in Full ❑ Outstanding Balance Due: G1 3j? / 4 6 g. 00 17 SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) d 8 q q yt--�? hIWV�1'( AlCC License Number Expiration Date Naine of Kb CSL-Holde List CSL Type(see below) Address Type Description U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling S. M Masonry Only J RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition S�Re istered Ho e m rovem t Cont act r(HIA G I z{ � ��?, � � `t 44-A HIC om a Nam r C istr t me Registration Number ��-npr�u <,m I � l rc s � 4lZzll 2 Ad ress 751 � (J Expiration Date Signatu 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 I, , as Owner of the subject property hereby authorize P'Ii, -f-PM c' c to act on my behalf, in all matters relative to work authorized by this building permit application. g j i natureofOwner ttbate�l �\\ SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION I, l �11�f'c�'S1.11 ACC L , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf„ Print_Name B �sv Sigdatur uthorizcd Agent Date (Signed under the pains and penalties ofperjury) 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors 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"maybe substituted for"Total Project Cost" The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): I G+� Nnl�1(�(ri� r MG Address: 140 4(,(I�tf_K�C ,YA i City/State/Zip: J T AAA 01q0J Phone #: 781 5$ ( a 53S Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 1 — 4. ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ❑New construction 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 workin 'for me in an capacity. employees and have workers' g Y P tY• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.- required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t 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. -Contractors 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. nc Insurance Company Name: Policy# or Self.-ins.Lic. #: G 5�O7t}970-12O�d n Expiration Date: 41?)&2 0// Job Site Address: R - 1 5 1 ✓'t RillY�. t,( 0& ►I�'l/l City/State/Zip: 0LG7n Attach a copy of the workers' com ensation 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 verification. I do hereby certify under thepains and penalties ofperjury that the information provided above is true and correct. — ldt�l� 'Siertature• Date: Phone 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#: 8/19/201' ' HIC Registration Complaints The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Mass.Gov Consumer Affairs and Business Regulation Horne > Consumer > Housing information > Home Improvement Contractor Program> HIC Registration Complaints Registration# 141448 Registrant GIOVANNUCCI BROTHERS Name BRIAN GIOVANNUCCI Address P.O.BOX 91 City,State,Zip SWAMPSCOTT,MA,01907 Expiration Date 4/222012 Status Current No complaints found for this registrant. You can also view arbitration and Guaranty fund history. Back To Search ©2010 Convmnw ealth of Massachusetts Massachusetts- Department of Public Safet%' Board of Building Regulations and Standards Construction Supervisor License License: CS 82453 Restrictedto: 143 BRIAN R GIOVANNUCCI 140 HUMPHREY ST SWAMPSCOTT, MA 01907 Expiration: 328/2012 ('ommissiuner Tr#: 17943 db.state.ma.us/.../licdetails.asp?txtSearc... , „