4 LILLIAN RD - BUILDING INSPECTION (7) � l 4-1°° cK ZS3�
RECEIVED
r�SPEC.TIONAL SERVICES
4
fheCummooW, ytofMassothuse-tts_
Board of BgtWmg RegulMnms;ml Slandatds CITY
Massachusetts State Butldtno Cutk, 71f0 C Ik T"edition OF SALkM
111 RrviF SAL M
Building Petm#Application T6.Constmct.Repmr,-Renovate(h Demolish a - 1. :()(AV
(hte-orTiwrFund/v Dwelling
?ha Section For O18ciel Uie On "
Building Peimil'Num' Due Applied:
SignuurV. L L5L.
RuildingCemmtssaner/T ,�_ WMW..: - . I>rt[e _ .
3 .
SEFTION 1 SITIN E FORMATION
1.1 hoper�y Address n 1 2rAsseasrs Mao l hreel Nn skleirk
y sCil1✓nriJ na
—' I L I a Is this an aecc ed atreei?yes no MaP Numbs - Pavel Nu l
t t.2 Zonlrg Informalben, I 1 Propmtr"Dtmhsloas:
Zoning District Pmposed.Use Lat Atm(sq M . :: _. ._ Fromage'(fl)"
FMv Ymd '_ :.. .. -Side Yaeds• =i - s, Resr-Ynd
Repured ..Nmided " , . ReVwred.-;,. , lioyWed :�. Required ... .Provided
F.
1.6WaterSupply:(M.G.Lc.4kfSp 1j,Flood Zone fafarmetlar. IJ. p.DtipuN'3yuam:
Zanm' Oibtds Flood Zaae4-
Pu61ie O Private O .>.: �i" '�' Mutddpal O On site
disposal
syssem .O '
SECT/ON2: PRbPBRTYOWNERSHIPt `.
2.1 Owner 4Raeordr" /
-Doev Y�J QG kL�jJ •l�G: /�rt� /2 D
" 7c97 4/
.;Tekpht,- "
9BC110N .DP3CR1p 17bN OR PROf'OBBD WORK(efiedt a11,tYt apply)''
New Consuuc:tion d' .Existing BbiWing 0 Owtur 0ceupted l� ;-ltepurs(s)'C Altartion(s) Addition 0
Demolition O Aoxuary BWg 0 ; :Ntunber of l7nits_'- Othg,O Speetfy; t ,
Brief Dmdption of Proposed Work
I✓£o!1 2 +�"h.. c :j'T [�r�. ✓V£4� r1f� ��t t /tc_ .
s.W La� 9�C { �.. Y I�'/ ✓1L LIiJ-'.:q"./9 LJ`;/
SEctrON l:IUTn 1iATED CONSTRUCT/ON'C` M
Estimated Costa:
Item (Laborattd Materiab OIIkJaI Use Oil
I. Building AA(3LW S $ U. !1? 1 -Building Permit Fee:f Indtciila how fen=is determined:
O Standard Ciry/Foivn Applii:uton Fee
2.Elecuieal f a2l. t J - s
O Tou1 Pm)ed Co>t (hem.6)x hitt liq x
3. Plum6in8 Is /b17. LJ 2 Other-Feesc f
4.;Mechanical,(FIVAC)• f List
S. MecltmdeaF-(Fire S
S c3�G�/G. Total All fem.f '
E Cheek No Check Amount Cash Amount
6.Total Project Coil: ` S ZJ� tfl'L� OPattiin,Full O,Outsiandin Balanee;Dua:
jV1) jD ULUMN) WtfiCN 2El'�D`{�
�MA4LZ70
i
sECTION S: COn3TRUCTaon JERvicES
E,q.jL,ke2,2�"
C�oast.roatoo Su�pce,r�wkisolr�C SL) 2D /7
IaroueNamber Eipiratim
Name of M.I14ddw _ List C5L-rype lace below)
— 1 -2 AV x L —ruw I . Deuri ion
� 'thueioictcd toJS000Cu.Ft.
' Resuielid,It2Fami -`Uwdlin :: :
RC: ReswadialRwr Coven
felnphwm - .WSlbitk»tId wtnJmiini'a Sah --
- SF,, - RaitMraiat Sdk Fuel "'A Itdtice Installation
D (. .-Raidemial-Demplition
s.2,p7�.��tend No��e��{m rww t Contnaoe(NIA
�lL�i—{ � — Regiwation Number
I IIC Company Name or IIIC Reguuom Nam: _ _
Zo b
EkPinuion Dot
sr arc Tnkpiwate
SECTIONf WORKERS!:COMPENSATIONWSIJRANCEAFFIDAVIT(MG.I.e. IS2.lj23C(6))
Workers Comperaattan lnsam" allidwo mrnt ba comPk d and submmat with tAis appliWioo Failure to provide
:this affidavit wnli rdultn dro denial of the iswgrce atdrobwldittg permo.
Signed Aflklwtt Attaehcd7 ., Yea , ..O _ ,,� Plo ,
T'SECTION 7a.;OWNBR AUTHORIZATION TO t!B COMPTED WHEN:
OWN SR'S:ACENO LE
R C,ONTRAC7'OR:APPIJ�4:POR BUII:DIIVG PEIIINIT
Owner of the s*ea property hereby
authorize /�6 �L 9 L 4 2 to ma an my behalf,in all matters
rclari w-°d�dr h a biuldtng pernut applkatbn.
Si orowner_
SECTION 7f OWNER!bR AUTHORIZEDAGBNT DECLARATION
y p��CsL�— as
Owner or AuUiorized Agent hereby declare
that the statements and information on die foregoing application ere thm and Mcurste,to the bolt of my knowkettge;aml
! LG Cf2S - -
°�
M tan t or
(Supp6d witier the pons aM' his of Per -. -
_.
1. An Owner who obtain■budding permit�o'do hta/he7 awn work or an owner who hrta an`unregiatered cororacta
(not registered in ihe'llarte Improvement Cantratla(HfC)pmpr mk will Ildhave acre s:toAbe arbitration
program or guamttty;fund under M G L e. 12A Otlui gnportmtt infatuation on the HIc Program and
Construction Superyifor Liceiuing(CSLt coif be found_ia 780 CINR Regulatioiia 110 Rt and TWA ,rapeetively.
:. When substantial work is planned,-provtde the mfomtation belowt
Taal Iloas area ISq.FL) (iitchrdirig garage finished basetnettVopks,decks a porch)
Gross living area(Sq:FL) Habitable roam cmtnt.
Number of fireplaces Number of bedrooms '
Number of 6atkrooms< Number of hal(>baths.
Type of heating system. <f Number of decks/parches.
Type of cooling system r'" Enclosed Open
). "Total project Square Footage"may be substituted fa .Titter)Pm)ectCost"
the Commonwealth of Massachusetts
Department oflndustrid Accidents
Office of Investigatfons
600 Washington Street .
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLMY
Name(BusinessAorgamzationdWividuat):
Address:
Pit3'/staft0p: Phone M
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employes with 4. ❑ I am a.general contractor and I
empktyces(tali 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 4 . . 7. ❑ "cling
ship and have no employees These sub-contracrors have 8. 0 Demolition
working for Me in any capacity. workers'comp.insurance
[No workers'comp.insurance 5. El We are a corporation and its 9' 0 Battling addition
required.] officers have exercised their lo.E] Electrical repairs or additions
3.❑ I am a homeowner doing an work right ofexemplim per MGL 11.0
myself[No workers' comp. c. 15Z 11(4),and we have no �1 repairs or additions
insurance required.]t employees [No workers' 12.[] reppairs
COMP.insurance required.] 13.0the Other
�Anyapplicmt that cbeelus box#1 muat also fill am the section below showing they Compensationwmbo,Contion policy ianndkn
t Homeowvers who sabm8 this affidavit indicating they mac doing an watt and then biro outside mnbactcas UNAsubsat a new affidavit indicating MVIL
tContaacbta that check this box mud attahed an additional abed showing the case,of Poe®b-oondenceas and their twtcm.comp.policy h fnTnaticNL -
I am an employer that LvproWmg workers'eompemadon hwurancefor my employees. Below it the paUcy andjob site
lnformadon.
Insurance Company Name:
Policy#or Selۥins. Lie.#: Expiration Date:
Job Site Address: Cyly4SMtdzip:
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 wen as civil peaiihies in Ste form of a STOP WORK ORDER and a fine
of up to$250.00 a Clay against the violator. Be advised that a copy of this statement may be forwarded to Me Office of
Investigations of the DIA for insurance coverage verification.
I do here undo ns and enaltfes ofpedury that the Informadorl above Is abo Is true correct:
Si ir `�`� Date: z 2� /6
Phone#: 20d"- 9132• - cf
QB`Icial use onfy. Do not write In this area,to be completed by eftyor town gj)FcfaL
City or Town: PermWUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cky/I'own Clerk 4:Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: phnno a,
Office of Consumer Affairs&Business Regulation
i
OMEIMPROVMENT CONTRACTOR
y1 istration 098BD ,F..:. r.-.TYPe
sue, IYaOon.�- '8� Individual
ROGER BOUCHEII
ig 1.�
koger.Boucher :
17 Linden Ave
} Salem,MA 01970 Undersecretary -
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-080914 '
��Tlti
ROGER P BOUCI R
17 LINDEN AVER IMF 3 .
SALEM MA 0197t1 < -
r
J� .Jrjn'' Expiration
Commissioner . 0510112017-. .
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic fee: (991m')of
enclosed space-
Failure to possess a cis urrent
forclOn of the revocatro of this license-
State
Building Cod
F.a DPS licensing information visit: www-Mass-Gov/DPS
4�
Town of Marblehead
Office of
TOWNS it
BULEDING C SSIQAWR
Robert&Iv Jr. SN&froF 76
�+ Mary A Alley MaaioipaI Building. tel: 781-631-2220
Commisslouer 7 Widger Road,Marbiehead,MA 01945
fax: 781-631=2617
DEBMS DfSPOSAL .
NIAP
PARCEL
BUILDING PER:AgT NUIVIBEIfi
IN ACCORDANCE WITH THE PROVISIONS OF 780 CMR 111.5,AND MOL o40,s54
A COMMON OF ISSUANCE OF THIS BUILDING PI$tivllT N TIIAT DEBRIS RESULTING
FR011f ANY WORK PERFORMED SHALL BE DISPOSED OF IN A PROPERLY LICENSED
SOLID WASTE DISPOSAL FACIIdTY AS DEFIINM BY MGL cl 11,s.150A
DEBRIS DISPOSAL LOCAnOAP 1
PICKeD V?
SIGNATURE OF APPLICANT
DATE Z Zo%C�
h
NO
TICS:
ALL DUMPSTERS OF SIX(6)CUBIC YARDS OR MORE ARE EEEQUWD TO HAVE A
PERMIT FROM THE MARBL EHEAD FIRE DEPARTMENT..CALL 78 1-639-3428.