3 LOGAN ST - BUILDING INSPECTION (2) 2-8 D c-r ti (0 L�
r The Commonwealth of Massachusetts ' ARV
Board of Building Regulations and Standards CITY LE"I M
Massachusetts State Building Code, 780 CMR 41U�6 JuL p A
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
�O Building Permit Number, Date Ap eds
Building 0111cial(Pont Name). Sigoalure
SECTION ti SITE INFORrNIATIOI*
1.1 Properly Address: LIAProperty
rs Ninp dt Parcel Numbers
3 LO/�N ST
` I a Is this an acce I street9 es� no Map Parcel Number
1.3 'Coning Information: Dimensions:
Zoning District Proposed Use - It) 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:
Public O Private O. Zone: _ Outside Flood Zone? Municipal 0 On site disposal system O
Cheek If es 3
SECTIONI: PROPERTYOWNERSHikt-
2.1 gqwner of Record:
fib L ..DAY �ALV mA • Oi97o
me(Print) City,State,. IP
.3 LOGAN dT 8S7-d07- —'11
No.and Street Telephone Email Address .
SECTION 3:DESCRIPTION OF PROPOSED'WORK'(check all that apply)
New Construction❑ Existing Building Owner•Occupied Repairs(s) t7 Alteration($) ❑ Addition O
Demolition ❑ Accessory Bldg.O Number of Units_L Other Specify: U)W-HCR I ZOMICI1
Brief Description of Proposed Work-:
1d/Si1LA7-E. A7T1G r LYYERIDA WALLS WJ7N B10GJi(1 I-,E4Z JLB.tE
SECTION a:ESTIMATED CONSTRUCTION COSTS
Itent ti"o
osts: Official Use Only
terials -
I. Building I. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical ❑Total Project Costs(Item 6)x multiplier x
J. Plumbing V Qther Fees: S4. Mechanical (FIVAList,
5. M1lechanicel (Fire "rotal All Fees:S
Su ression) Check No. Check Amount: Cash Amount:
6. ToCtl Project Co ❑Paid in Full ❑Outstanding Balance Due:
ASH, t,3 Cy tJ
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ( JO n 7-51
L 80 61 �NOfF 'i License Number Expiration Date
Naale of CSL HUlder List CSL Type(see below)
JS MAWA! Ab Type Description
No.;tad Street
U Unresuictcd Buildin u g to 35,00 cu. It.
�frAKEFi�La rail t�lSBo — R Restricted )&2Famil Dwellin
City/I'own,State,ZI M Masonry
RC Rocifinst Covering:
WS Window and Siding
/ SF - Solid Fuel Burning Appliances
1 1 Insulation
Tcic hone Email dress D Demolition
5.2 Registered Home Improvement Contractor(HIC) f I oSo-5r, M_�2
sTIGCA (ADAITQAC7�/Nl C�• — HIC RegistmlionNumber Expiration Date
HCugipmty Name or HIC Registrant Name
Z�fp Mhwc%OAl s,'
No.mid Street - Email address1PAJ-D el A.4, OZI yIP I
Cityrrown,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.QL a 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 ..........MO' No...........Cl
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED,W HEN'
OWNER'S AGENT OR CONTRACTOR APPLIES FOtt BUICDING PERISIIT
4 as Owner of the subject property,hereby authorize S7,lCL-,4 Cd A)I C-r46 CO
t9 act on my behalf,iqLAmatters relative to work authorized by this building permit application.
Print O icr's Name(Electrot Signature) Date
SECTION 7b:OWNEW 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 accurate to the best of my itwledge and understanding.
,� ncc ad�f a��i6
Pain Owner's or Authorized Agcnt's Name(Elcetronic igimlure) Date
NOTE
1. 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 lmprovement Contractor(HIC) Program);will no have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC-Program can be toun 3t
www mass eov'oca Information on the Construction Supervisor License cam be found at www.mas�
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. R.) '� .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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
1. "Total Project Square Footage"may be substiluted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office eflnvestigadons ,
9 600 Washington Street _
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ApnIfcant Information Please Print Legibly
NaMt(Business/Organizatinn/lndividual): s'77eCA IA�YI�AL�/7A(� (Li,
Address: 271 /IDO-CNiNr raw S-7,
City/State/Zip:�L� dA. jula Phone #: //7:f4-2- 4M
Are you an employer? Check the appropriate box: Type of project(required):
1.ER I am a employer with_ eZ 4. 0 I am a general contactor and I 6. ❑New construction �
employees(full and/or part-time).' have hired the sub-contractors
2.13 1 am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working forme in any capacity, workers'comp. insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MG l l.❑Plumbing hairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers'
co insurance 13.❑ Other
top. required.]
Any[pplicaat that cheeks box el mustalso fin oui the section below showing their workers•compengdm poky information.'
t Harneownen;who submit this&Mdavlt indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating suck
*Contractors that check this box toms attached m additional:beet showing the name of the sub-cautraeams And their worker'eornp,policy infotmatioa
I am an employer that is providing workers'tontpensation insurance for my-employees. Below is the policy and job site
information.
Insurance Company Name:ZU/Q/U/ A/1JEtQ MAI
Policy#or Self-ins.Lic.#:_ 4 ZZURr94V 9N43,21 Q Expiration Date. _y—5-17
Job Site Address: city/State/Zip: rA/tm top CS/970
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 51,500.00 and/or one-year imprisonmatt,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of no to S250.00 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.
I do hereby eottfy.under the pains,and penaldes ofpedury that the information provided above is true and correct
Sigrattire: .sl�i� Date 1�—/L
Phmme#: �1?-s9s- �giy
Offcin!use only. Do not write in this area,to be completed by city or town official
City or Town: Permlt/LI[Cnse#
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#:
- comtracum Superwimr
BRADI.EYDANOW _
15 MARION ROAD
�•�""•'�''�' . p118V20tT
unreMcted-SAA&W of any um group which
comm I 35.000.COW€eat(99IM-)of
andawd spem _
Fagum to possess a amw*edMw+of the htassachusens
stme aWWM Cmk4cmm for revota5onof this ikeme.
For ws UrwAeaietanatllenvift rwwAUSLGarNR
Office of Consumer Affairs and Business Regulation
10 park plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
R mtelion: 110505
Type: supplement Card
Expiration: 10/20/2016
STICCA CONTRACTING CO
BRADLEY DANOFF _ _.. ..
376 WASHINGTON ST
MALDEN, MA 02148
Update Address and return card.Mark reason for chaagc
1 Address Rm,,,al ! ! Employment i 'i Lost Cerd
Otuec of Commmer Affairs&Business Relt"Uoa License or registration valid for individul Use only
R before the expiration date. If found return to:
E IMPROVEMENT CONTRACTOR Business Regulation
HOME e f Consumer Affairs and B eg _
Office o
neghtreUon: 110505 Type: 10 Park Pura-Suite 5170
Expiraton: larA 016 Supplement card Bastna,NA 42116
STICCA CONTRACTING CO
BRADLEY DANOFF
376 WASHINGTON ST
MALDEN,rdA 0214e � � Not valid ithont signature