188 MARLBOROUGH RD - BUILDING INSPECTION L.
G�1� o)0 3 3
the Commonwealth of Massachusetts rRevisedihw
Y OF
Board of Building Regulations and Standards LEM
Massachusetts State Building Code, 780 CMR 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
(70 This Section For Official Use Only
Building Perm itNumberr Date.A ied:
MOr rl I9/��
r! -0uilJing 011icial(Print Name). - Signature Date
n SECTION li SITE INFORbIATION
e 1.1 Property Address* L2 Assessors Map&Parcel Numbers
IRR Marlboros) RG,
I.In Is this an accepted street9 yeses no Map Number Parcel Number
��- 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District .Pn+posedUse Lot Area(sg11) Frontage(11)
1.5 Building Setbacks(R)
- Front Yard Side Yards Rear Yard-
Required -Provided Requited - Provided . Required Provided
1.6 Water Supply:(M.G.L c.d0,§54) 1.7 Flood Zone Information: 1.8 Sewage/(�isposnl System:
Public Private O. ZOOB — Outside Flood Zone? Municipd gef.On site disposal system O
Check 1f esO
SECTION I:_PROPERTY OWNERSHIP
t
2.1 Owner'S�f Record: V49A AA
[I Abe 166! 5 City,Slate,ZIP . .
me(Print)
I� y2P-Z.�A Q(I 4)f�Sz �r1�,�D�LhPSN (OWI
No.and Street Telephone - Email
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction Existing Building O Owner-Occupied a -Repairs(s) O Altemtion(s) O Addition O
Demolition 13 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
p pu vt 07 6sv1
At" rC�' 19,1
SE ION a: ESTIMATED COSTT UCTION COSTS 3
Item Estimated Costs: Official Use Only /7
Labor and Nlaterials I I - - - /1/
I C Building S 1. Building Permit Fee:$ Indicate how ree is determined:
❑Standard City/Town Application Fee: /v S
2. Electrical S ❑Total Project Cosh(item 6)x multiplier s
7. Plumbing .5 P Pther Fees: S
d.imcchanical (tiVAC) S - - List:
5.Mechanical (Fire S Total All Fees:S
Sit ression)
Check No. Check Amount: Cash r\mount:
6.Toi Paid in Full 13 Outstanding Balance Due:
'VA
SECTION 5: CONSTRUCTION SERVICES t.
5. Construction Supervisor License(CSL) !J J 7� D Z 1
' 0 License Number xpiration Date
-
N:i ne of CSL Holder
List CSL'fype(see below)
Type Description
No.and Street
J 1 I J R RestrictedI&2 F:unit Dwellin
City wn,State,ZIP I M Masonry
RC Roollnx Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Sz Y9�7 �f 7U h(x1G��s e q rr7 4)1'(O I I Insulation
Tcic hone Email address/ D I Demolition
5.2 Regstered Hoyle Imptlovement Contractor(HIC) I 0 6Q � �
i 2
6C')ovv- \ u/C)(7 CVLLO HIC Registration Number .piru ion Date
HIC Company Name or HIC Registrant N me
_��P 1����,1�J�c�i°� @gYnai Fob
No.mid Street Email alldress
Ci /Iwvn State ZIP Tele hone
SECTION 6:WORKERS'.COINPENSATION INSURANCE AFFIDAVIT(M.G.L c.10.g 2$C(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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION 7o:OWNER AUTHORIZATION.TO BE.COMPLETED.WHEN?
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT`
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all mat rs relative to work authorized by this building permit application.
A PS -L )�
Prin owner's Name(Electronic Signature) _ D to
SECTION 71b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application
lis true and accu to the best of my knoppledge and understanding.
Print wner's or Authorizcd Agent's Name(Electronic re) I Onto
NOTES:
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.Improvement Contractor(HIC)Program),will gol have access to the arbitration
-- ---
program or guaranty fund under M.G.L.c. 14-2 Ot-her important information oniheNlC-Program can be noun 3f
www mass cov'oca Information on the Construction Supervisor License can be found at w�aw.mass.nuv,'dns
2. When substantial work is planned,provide the information below:
"fotal floor area(sq. ff.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating systein Number of decks/porches
"fypeofcoolingsystem Enclosed Open
7. `Total Project Square Footage:"may be,ubstitutcd for"Total Project Cost"
iM
CITY OF SALEA A ASSAQRSE M
Bu zDncDEPAjmffwr
120WA9 GTQNS7MW,3PRDOR
IkL(978)745-9593.
PAX(978)740.9846
BINJBERLEYDRISQ7LL
MAYOR 7) MU STYMM
DntEcrcotcFmmucnxvzmlBumDncoommmoff=
Construction Debris Disposa/Afdavit
(required for-all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris;
and the provisions of MGL c40,S 54; Building Permit d is issued with the
condition that the debris resulting from this work shall be disposed of in a property licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by.
Lev CY aLd SOhd li/4s4e .
(name of hauler)
The debris will be disposed of in:
(name of facility)
(addre s of facility)
Signatur f applicant
ylz� b _
Date
The Commonwealth of Massachusetts
r Department oflndustri r/Accidents
i
I Congress Street, Suite 100
Boston,AL4 02I14-2017
www massgov/dia
§`orkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNEM ING AUTHORITY.
Applicant Information Please Print Leeiblv
n/Ind
Name(Business/Organizatioividual): i /Cyr) -5 dLn �on wt kw C o i o 7
Address:_I q 4PZZN n d
City/State/Zip: -eVYAlW A Phone#: y 9 6
Are you an employer?Check the approp 'ate box:
1.[�I am aemployer with�emplo s full and/or Jk-g
Type of project(required):
e ( part-n7. New construction
2.❑I am a sole propdetor or partnership and have no employees woform in $. Remodeling any capacity.[No workers'cemp.insurance requtedj ❑ g
3. I am a homeowner doing all work9. ❑Demolition
❑ 8 myself.(No workers'comp.i requuedj t
4.❑I am a homeowner end will be hying wntactors to co�uct all a property. I will 10❑Building additionensure that all twntractors either have workers'compensation inor are sole 11.❑Electrical repairs or additionsproprietors with no employees.
12.❑Plumbing repairs or additions5.❑7am a general contactorand I have hired the subcontracmrs lise attached sheetThese sub-contractors have employees and have workers'comp, co.t 13.❑Roof repairs
6.❑We are a corporation and ier officers have exercised Weir right ofon per MGL c 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.ma quired.]
-Any applicant that checks box#]must also fill out the section below showing Weir workers'compeusation policy information.
IHomeowners who submit this affidavit indicating they are doing all work and than bin outside contractors roust submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub=contractors have employees,they must provide their workers'comp,policy number.
Ions an employer,that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
informaden.
Insurance Company Name: )c♦-
Policy#or Self-ins.Lic.#: I- I t n Expiration Date:
Ul
Job Site Address: City/State/Zip:
Attach a copy Of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cert6 under the pains and penaa ties ofperjury that the information provided above ' /true and correct.
Signature: /U�. )�/lA t 6z jtt Date:
Phone
Fuse only. Do not write in this area,to be completed by city or town ofcial
n, Permit/License#
ority(circle one):ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspectorson• Phone#'
Information and Instructions T
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,corporation 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."
MOL 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-contractor(s)name(s),address(es)and phone number(s)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
be 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 on the appropriate line.
City or Town Officials
Please be sue that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sue to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemuUlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia