24 LYNDE ST - BUILDING INSPECTION (3) \ The Commonwealth of Massachusetts
(� ► 1
Department of public Safety
Ias.S,I111usrlISS1,1 IclluildingC,Me(780C\IR)
Building permit Application for any Building other than a One-or Two-Family )
1 ("I'his Section Fur ?ffit. I Use Only)
Building permit Number -- Date Applied: ._ Building Official: -
tiECTION 1: LOCA HON(Please indicate Block B and Lut fur locations for which a street address i available)
NO.and Street City /Town Zip Code Name Of Building(if applicable)
SECHON 2: PROPOSED WORK -
lidiliun of Ah\56rte Crate used If New Construction chock here❑ur check all That apply in the two rows below
iixisling Building Repair :\Iteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill urn mid submit Appendix 1)
Change Of Use ❑ 1 ChangeofOccupancy ❑ Other ❑ Specify:__--- _
Are building plans and/or constntctiun drx'wnents being supplied as part of this permit application? Yes ❑ NO 61 --
Is an Independent Structural Engineerin, peer Review required? L� Yes ❑ No l/
Brief D�}scriptiunuf Proposed Work: etn.S
_ . 1' C��1,JVlC�2d:lN1, P,-x+eYiPs( CAA.
SECTION 3:COMPLETE Fills SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 ChIR 34) O
Fisting Use Group(s): . —_ Proposed Use Group(s):
SECTION 4: BUILDING IIEIGIIT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Fluor(sq. ft.)
Total Area(Sq. ft)and Tula) Height((t.) �
SECTION 5: USE GROUP(Check as applicable)
\: Assembly A-I ❑ A-'_❑ Nightclub ❑ A-1 ❑ A4 ❑ A-5❑ 1 B: Business ❑ E: Educational ❑ _
F: Facto F-I ❑ F2❑ FI: High Hazard H-I ❑ H-2❑ H-t ❑ li-�4❑ li-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-1❑ 1-4❑ �VI: Mercantile❑ It: Residential R-113 R 2❑ R-7❑ R-4 ❑
S: Storage S-I ❑ S-_'❑ U: Utility❑ Special Use❑and please describe below:
.. ,>a.
Spacial Use
SECTION 6:CONSTRUCTION-IYPE(Check as applicable)
IA ❑ Ili ❑ IL\ ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ Vil ❑
S ECTON 7:SITE INFORMATION(refer to 780 C,IIt 111.0 for details on each item)
Water Supp Y: Flood Zone Information: Sewage Disposal: / Trench Permit Debris Removal:
I Check if Outside Road Zone❑ Indicato 111LIO cipal EI 1 trench will not be Licensed Disposal Site❑
I'rivalo❑ ar indrnlity Zone: . or on site sn stem ❑ required ❑nr trench Or Specif%. -
- - permit is enclosed❑
It.tilruad right-of-wa I laiards to .\ir Nov igatiun: V I I r.1., • ....
.\'nt:\pplira blc E IS tit nicturr within airport ap Oarh •vra? Is their w%ir+c ionildclyd'
Or Gnnrnt fu Build vnrlu+od❑ 1 es❑ or..\'o Yas❑ \'o ❑
SEC"IION 8:CON LENT OF CHO IFICA I F OF OCCUPANCY
I`ditinu A COdo: .. ... C\r Gnm p(,): _ .. I\pv of lon,tfucliun: 0,up.utl LnaJ par Hoar
I tor, Ihr Building t onl. m on 1;Prmklcr Svslrml: tiprriul tilipulaliora: _ . . _
r ,
SEC"IION 9: PROPFRTY OWNI(R AU'1'IIORIZA"IION
Nome fit([ Addr•ss of Prop,ell'Owner i'
wcasL4,in SF Z-M&LKyC lau1Pf—/t-/�
N.Nt Nu. •md Street Cit)/Town ----0--/9y-
.--- --.—__--.-
Zip
Prpperty Owner Contact Information:
nlctc9 . LVVW sAAC-11 ,Z.r�-_��- I3'Z
Title TT�— Lelephune No. (business) Telephone No. (cull) c-m.til address
If.lpplicablu, the prop ty owner hercbv authorizes
;,-I Vwtif `irG�, l,crt sz. _ 6(mucesf dl93d
_. .. Name Ra�.p �>•• f Street AddressiYe(A**(ecdZ- City/Townes e�te�q Zip
Io act on the property owner's behalf, in all matters relative to work authorized IV this buildillS permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if huildin is Icss than?i3OQ)cu.ft.of enclosed s+ace and ur not under Construction Control then check here O and ski Section 10.1)
lo.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name p
( :otl 1/4y17 if VcarrsM"c{r
Name of Person Responsible for Construction License No. and Type if Applicable
,if tiefAlm '" Sf (.t."UC,3/¢� W 0I230
Street Address City/Town State Zip
Tole phone No. business Telephone No. cell o-nnail address
SECTION 11:m, _p}_axWI_',`Ant IN, fy�•ul \.\cPhf1111AV1J. M.G.L.c.152. 25C6
A Workers'Connpensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this a lication? Yes O No O
SECTION 12,CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) =S_
1. Building S Building Permit Fur=Total Construction Cost x_(Insert here
3. Electrical S appropriate municipal factor)=5
t. Plumbing 5
J. Mechanical (HVAC) S Note: %linimum fee=S _(contact nmun ipahh')
3. \IechaniC,ll Other 5 Enclose Check payable it (�
tp.Tidal Cost S -----
G '— (rnntaCt municipality')and a rite Check number here --_—__—_
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Ity entering nv name below, I heret,v attest under the pains and puny It ies of pe rjury that all of the information contained in this
pppincalion iS Inwood lCt�it IV tthe +•+t of m1 kri'm Icdye and understanding.
G f 7- Nd (3 y z V Y / 2
I lapse print and igo name I tie folk-phone No. Do c
5+_ lln r - �fitor 6 . -_
; rvet Address City/Town Slate /ip
Municipal Inspector to fill out this section upon application approval:
Name D,oe - --
�G �r.
Office of Consumer Affairs B so
Rego anon
_ HOME IMPROVEMENT CONTRACTOR
Registration:,,,',114241 Type:
t Expiration 811 612 01 3 DBA
WItt-/NORMAND CARPENTRY/,
WILLIAM NORMAND ,,4,
45 WITHAM ST
GLOUCESTER, MA 01930:= Undersecretary
Aiassachusctt's - Dcpattmcnt uP Public Safch Board of Buildim.1 Rc�ulntiuns and Shmd:u•ds Construction Supervisor License
License: cS 49997
WILLIAM °R NORMAND r:r.
45 WITHAM ST
GLOUCESTER, MA 01930
Expiration: &4/2012
f lmnuiv+inner
Tr#: 31472
CITY OF S.V-&Nr, Alss.kaa:SET1'S
OLILDLVG ❑EP.m-nosT
I _'0 W.ISNLNGTON STIM, 1i4 ELOOII
rM k978) 745.9595
PVc(973) 7�9846
'U1®t:1tL5Y DRLSCOLL
MAYOX MOMA,fST.PM S
0IIIECTOR OP PL SLIC PROPERTY/st;MDLYC Cos 01ISSIOVEA
Construction Debris Disp0531 Atfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 C,&/R section 111.3 Debris, and the provisions of MGL a 40, S 34;
Building Permit E is issued with the condition that the debris resulting from
INS work shall be disposed of in a properly licensed waste disposal facility as defined by ,&1GL e
III, S ISOA.
The debris will be transported by:
��rQ � D�so�sa0
(name orheuler)
The debris will be disposed of in :
Ali c �....
—_ (name of racilily)
2 y r CO',^fi,41 / s)
(iddrets of rjml,iy)
u�nanrroofpermrtpphunr —
•,'ate
Co"L m
LYE, )�
i
"' CCI'Y OF S:1LEa�I, ,1 L15S:1CHL5ETrs
13L'ItDING DEP.IRTMENT
?°� '� s' t�% 120 WAN STREET 3"a FLOOA
� �''` '�� TEL (978) 735.9595
FAX(978) 7104846
t<1_\(I3 R[ FY DRISCOLL
MAYOR I Honits ST.famuit
DIRECTOR OF PL OIL IC PROPERTY/SUn.ONG COWMISSIONER
Workers' Compensation Insurance AtIld'avit: Ouiiders/Contractors/Electric[ans/Plumbers
4 a /llcant Information PICAtle Print Lea[bl
.NJITIC Inert ilk-,WrWmtraliuru Individual l: LW0I'6%A1 IVG1 h'tC
Address: 11f Wtf Gltm Sr 6l(G'4JCL4y, W i l3c>
City/Sratc/Zip: Allf 0i93v I'honC#! 97Y- ?d'3' elvj•—
,ire you an employer'!Check the appropriate boat JP
project(required):
1.�] I am a employer with , 4, 0 1 am a general contractor and 1aw,construction
,�,�mplo'ecs(fell and/or part-time).• have hired the subconlracton
2. 'L'I I am a Wier proprietor or partner• listed on the uuachad.rheua temadaling
.hip and have nu employees These subcontractors have entolilicn
working liar me in any capacity. wcrkars'comp.Insurance. uilJing additiono workers.cmnp, insurance J. 0 we are a corporation and ivreyuirud.l officers have exercised their lectrical repairs or additions3.0 1 ran a homeowner doing all work right ofexamplion per MCC lumbing repairs or additionsmyself.(No workers'Gump. C. 152, 01(4),and we have no oof repairsnsuannca reyuireJ.) r employees [No warlters' 1hcr
comp,insurance myuimd.l
\,iy irplk:un IIW rhmar boa rl muar Abu fill our IN ratiue but**
ahawine(hair"it".campawdun Puliuy inlLmroeon.
I N"VOWMW who whmir this aMdavit indiaina ih y are chine all'wrt and then hirs outride...tn,so,mini n trill a raw rnl4vg inditolingt,"k
/'mtrxtun that shish this bux mmt anachod an addidunul.it wt nhuwine the nwno of the sub.ualmu,.,r pad that'wnrkao'camp•policy Inrartru ice.
fain on nnpluyer that/r pruvlding Ivorken'rumpauar/on Lrxurunceyor my ernpluyees. Below is rlle policy and job site
in�unnadnn,
I n.,urance Company Name: _
Policy 4 ur Self•ins. Liv. n: Expiration Date:
Jab Site Address: Cilyislata/Zip:
.\uacb a copy of the workers'campansattoe pulley declaratlan page(showing the policy number and espinllon data).
F.liluru to wcuru cuvdngt:as required undar 3cctio 9 n 21.\ofNGL e. 152 can lead to tha imposition of criminal penalties of
tiro np to S 1.500.00 undlor one-year imprkanment,as we11 as civil penalties
of ull its Sn_i0.00 a Jay against the violator. 11e advi.+ed that a cu if in the Farm ul•a STOP WORK ORDER and a line
py Ihis,tatcment may bu furwurdcJ to die 011ica of
lavrsli gat in 'it ti the q1A liar insunnca cowrngc vcriticatiun.
!Flu lrrrrby rrrri turd the pu' r mrd prnulrlrr�r�p.rjury r/rut rho infunrralla'provided ubuv it 1 e surd eorreca
46
U//iciul rue wdy, 17"uor wriu in Ilr/r urro, 14 be c muplet.d by Lay of town ujjlriat
City.tr I'uwnt PcrmitiLlecate i
!„ui n,a,.\ullnarily (circler uac):
I. 1luard nl Iteallh !, liuiidln�."Ucp.lrhnenl I.C'ilyi Torvn Clerk t. Fl.ctric.l Intto ior i Pltnnitinv fillip
or6. )lhr
l�utlu.t i'ertui l: