497 LORING AVE - BUILDING INSPECTION I �
Flte C'omnwnwealth of Massachusets
kibi',"Iding
Board ofBuilding Regulations and Standards CIJOFMassachusetts State Building Code. 730 C'NIR SABuilding Permit Application To Construct. Repair. Renovate Or Demolish aOne-ur Tmvi-Fuuii(r Duellin,(rThis Section For Offic' Use Onl Permit Number. Dat Applicd:
g Ullicial(Print N,unc) Signature (
SECTION 1:SITE INFORMATION
1.1 1 Property Address: 1.2 lssessurs NIsp& Parcel Number
I.la Is this an accepted street?)-es no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
S7ar
Zoning District 1'ropuseJ Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
"of
ront Yard Side Yards
Rear Yard
Provided Required Provided Required Provided
upply:(M.G.1.c.40,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal s +am ❑
Check if es0 P pos )s
SECTION 3: PROPERTY OWNERSHIP'
of Rec,Qrd:
Tlee,City.Slate.ZIP
o f,'av Ads
Nu.and Street —� Telephone Entail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairsis) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and.\laterials) 011tcial Use Only
I. Building 5$000 C) C7 1. Building Permit Fee: S Indicate how fee is determined:
�-. Electrical S ❑Standard Ciry� own Application Fee
❑Total Project C'ust'(Item 6)x multiplier x
1. Plumbing S -
. Other Fees: S
a. \Icch:mic,ll III\'.\(') S List:._ .-__
' S. .\lech-niical I Fire
Suppression) S rot l All Fees:
Cheek No. ('heckAmounn Cash \mount:
n. Total Project Cost: ygQp O 00 ❑ Paid in Full ❑Outstanding Bal:mcc Due:
d6 �G�f�
SE("IION ,5: CONS"FRUC'ri0NSERVICES
5.1 Construction Supen'isur License(CSL)
/ n Lwrnsc--Lo12 L.s7-- --- .S L
Nunther P pir; Ion Date
' N;uneul'l'Sl. 11nlder
I isl CS I. 1')Ix Is"1lehtm)
091.f A/�Q��---s — - -- ---- I'}pe Ikacriptiun
Nu, .utd Street
U I I resiricted Illuildin ks up ht 15,11110 of 111
L�/_Il_�Yr� /asS _ 0_��1.__. . R It icI-d Irk rantil ' Dttcllin
C•it) aft n.Rt le.LIP M1I klasoory
FEiRC Roolin C'm erin
I AS I Window wtd Sidin
5F I Solid Fuel Burning Appliances
/�S 59/L// I htsululiun
'fete hone h:mail address D Demolition
5,2 Registered home Improvement Contractor(HIC) IV17 7 r- CL
Xj/J��;ram,., T,/}koZ 7,P ton r//! I IIC Registration Number spi uiuu Dutc
I IIC'C'ompuny Nano or I IIC'Rcgiitmat Name
J/ L/P20A" S�
-0 wld Sreel Email address
�l�nil 104.r5 oi9oy ]8/5�99/z //
Cit /Town,State,ZIP role hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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...........C)
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name Electronic Signature) Date
( 8
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
contain[d yQ iis aj. i vstru and to the best of my knowledge and understanding.
"(mil j//I J2 8 l
Print Omncr'i or:\uthorireJ \gent's nn flcclronic Signature) Date
NOTES:
I. :In Otvner 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 no have access to the arbitration
program ur guaranty yard under\I.G.L.c. I J?A.Other important information on the HIC Program can be fitund at
Dort 111.1.1 Ot ;y,I Information on the Construction Supervisor License can be found at nle.+ �10% III,
2• \Then substantial\cork is planned, provide the information below:
Total flour area 1% It.) _ _—__--_(including garage. finished basementattics,decks or porch)
Gross lit ing area Isq. ft.l _ _ Habitable room count
\wuberof fireplaces_ _ Numberofbcdruunts
\umherol'bathrooms _ _ \umberofh;dfhallis _
I
I)pc of heating s)item Number of decks, porches
I\peidiOUhllgitStelll 1,11closed _ _ Open
1.I
1. "focal I'rojcct Square Footage"nip he iobstim icd Iiv"I'otal I'rijw Cost"
CITY OF Sm ENt, %WS.ICHUSETTS
BUILDING DEP.IRTME.\T
+ ) ! 120 WASHLIIGTON STREET, 3 FLOOR
``�•` TEL (978) 745-9595
Rit.X(978) 740-9846
Kl.%tBERLEY DRISCOLL
NLAYOR _MOSIAs ST.P1FRRS
DIRECTOR OF PUBLIC PROPERTY/8UIIDTNG CO%LZIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciausiPlumbers
,koplicant Information / Please PrintLegibly
V;InlC lnuriixss.Urgani:afiomimlividual):� /�ti T�/.'/1�/17� sort yY1 C_
Address:QIS� 1/Prion!s
City/State/Zip:L./12'1 11210fr- Phone V
_ Are yt an employer?Check the appropriate box: 'type of project(required): .
IX I am a employer with 17, 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time).* have hired the subcontractors 6. ❑New construction
2.❑ lain a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
,hip and have no employees These subcontractors have g. ❑ Demolition
working for mein any capacity. workers'comp.insurance. q, ❑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 MGL 11.0 Plumbing repairs or additions
myself.(No workers'camp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance«suited.]t employees.;ees. (No workers' 130Olher�C� A�e,�
comp.insurance«gaited.]
•M u:a din y appin ehccks box II mwt alwa fdl as the U"M below showing their woikeri corpenudon polity information.
;Any
hweowntr who mhnrlt this affidavit indicating they am doing all wort and then hit outside contractors trial suhmb a new antdaritindialiny each,
Cnnrwtur that cheek this box must aaachud an additiurud cheat showing Ida owns otthe subaat uaxlors and their worker'sump,puliey infarwtion.
l um an employer that is providing workers'eampearatlon insurance for my employees. Below is the policy and Job site
injornrallom
Insurance Company Name:
Policy 4 or Self-ins. Lie. d: S/I 7 SQ 6. 7_— Expiration Date: A? �y.
Job Site Address: / / GD r fn�_�} /P City/State/Zip: F - l/-L t
attach a copy of the workers' compensation pulley declaration page(showing the policy number and explratlou data).
Failure to secure coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 und/ur one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S250.00 a Jay against die violator. De advised that a copy of this statement may bu furwardcd to the office of
Invcstigwiuns al'Ihe DIA fur insurance coverage verificalion.
I do hereby r'errijy a Ge paLrs m r ties aj erjury dint tlio iujormation provided ubu a is True dnJ i•orrrrG
L
wily. Da trotwrite irr tins urea, m be completed by city w tawnajjirtai
n: PcrmiUl.lccnse.dlharity(circle one):
Ilcolth ?. lluildinq Deparunent i.Cilytfawn Clerk J. Electrical Gtspecior 5. Plumbing; Inspectorrson: Phane:i•
i
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as".-every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporatioa or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance'coverage required."
Additionally.MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contmctor(s)nume(s), address(es)and phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number an the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant.
u as a reference number. In addition an applicant
Please be sure to fill in the permit/license number which will be used pp
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lob Site Address"the applicant should write"all locatons.in (city or
town)."A copy of the,affidavit that has been officially stamped or marked by the city'or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
'rhe Department's address, telephone and fax number:
The Commonwealth of Massachusetts'.
Department of Industrial Accidents
O[ftce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-7274900 cxt 406 or 1-877-MASSAFE
Fax#617-727-7749
Rcviscd 5-26-05 www.mass.gov/dia
Cin OF S,V-&Nf, j%LkSs.kCHL'SETTS
9L'tI�LVG DEP.IRT\lE,�;T
120 W.13HLVGT0N STRW, j o FLOOR
TEL (978) 74S-9599
K1Jt3ERL12Y ORMOLL F.uc(978) 740.9&9
.tiL1YOJt no.+W SLP>E u
DIRECTOR OF PCBUC PR0PERTY/81:mDC4G CON01ISSIONER
Construction Debris Disposal AttIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CUR section 111.5
Debris, and the provisions of MGL c 40, S 54,
Building permit p is issued with the condltion that the debris resulting from
this workshall be disposed of in a property
I5
111, SOA.
licensed waste disposal facility as defined by MGL c
The debris will be transported by:
(nano ot'hauler)
The debris will be disposed Orin : p rtJ G<
((name o►facltlry) "
�rVlh or
T
� dn+tire ofpermif Jpphcmf
hn vd !,y
11/11/2011 15:36 9785310757 NSCAP I PAGE 01/01
3• .� - rage Nu. of Pages
a aftxtgxna �x C
WM. TRAHANT 1R. CONSTRUCTION, INC.
4TH,GENERAT.ION ROOFING
215 Verona Street
LYNN, MASSACHUSETTS 01904 H.I. LIC. #141778
7�
(781) 599-1211 t(781) 844-4551 •FAX: (781) 581-0855
PHONE DATE
PR(0��09,�SUOMIftED[TMp..c
riorp' P.��.RC�• .we Nrmt: IP�J
STREET
LoR:k)G. E.
JOB I,OrATldtl
CITY,STATE and aP DDDE '
ons and estmates fa;
we hereby submit specifications and estimates for: We hereby submit specticati
FLe'rAuBBER ROOF --
QrSfr' entire roof _ 0 Sweep entire roof clean .
Rotate any bad boards up to 100 linear feet ❑ Strip entire roof
Ins Nice and water barrier first three feet up roof ❑ Mechanically fasten down ISO board insulation
In Ice and water barrier in all valleys and along dormers ❑ Install 060 Rubber Roofing on entire roof —
�nY51b.felt paper on remainder of roof w �— ❑Install metal flashing around perimeter of building.
Ins kt�ght loch drip edge ❑ Flash chimney(s), pipe(s)and wall(s) _
a Edge caulk all seams
n5 fi�p,L`ver46 .. - -
h or re-flash chimney(5I 'Iv7$1 AIL ❑Install new copper center drain
nns1 II new pioe
pe flanges ❑ Other:
stall 30 year shingle ❑ ❑Clean up all debris _
❑ Install gutters and downspouts. Y ElLabor and materials guaranteed 100%for five years M
Q Install trim coil ---
❑ Install new fascia boards _ _ _ _Cc•l.l�hAW " --�`—An
❑Install new rake boards _ _ ----- —
❑ Install sky fight(s).
❑ Othe_r:— A—
Clean up all debris
Lab
and materials guaranteed 100%for five years
It shingle roofs are nailed by hand.
>: r,a}ncsd hereby to furnish material and labor — complete in accordance virth.above specifications, for the sum of:
Total Price($ ��OCL•2(�—)
�*IF YOU ARE HAVING YOUR ROOF STRIPPED, PLEASE COVER ALL VALUABLES IN ATTIC, AS
WE HAVE No CONTROL OVER DEBRIS THAT MAY FALL THROUGH ROOF BOARDS. '
All mffwW E guaranteed to be as speclaee Al work to be conroleted In a norlurenrike Authorized
manner,mcordbw m standard prsc*=Any akeratpn or deviation from atme 3pecMC2,
tons Irnoldng extra costs wt be axocUU.d sly upon wrlden orders, aria wil become an signature_L•L�e!—LLB/—`-r.•�l " .
extra charge over and above the estmate.All 411 Mmente contingent upon Ltrikdn,
aeclee,as er dHaY-beyMd our control.Darner to canry foe,tornado,and other necessary
Insurance.Our workers ere My covered Insurance. l
C
pta=e of Proposal—The above prices,spectlrationsiibbons are satisfactory and are hereby accepted•You are authorized to Signaturerk as specified.Payment veil be made as outlined above.
rceptanctt — ����"�� Signature
oov,mpr to above odor¢ —