194 1-2 MORBORO RD - BUILDING INSPECTION --- I'he C'onunumcealdt of Massachoscits Cl Board ol'Building Regulations and Standards SAL OF
' EM
Massachusetts State Building Code, 73B C'NIR �d I1,11.
R��ri.+.•il 16rr_'rill
Building Permit Applieatiun 'fo C'unstrucL Repair. Renovate Or Demolish a
One.or ran-Funulr Uuellinp
This Section Fur Official Use Only
Building Permit Number: Due A plicdd:
47sro --
Building 0111cial(Print Mune) Signalure Date
SECTION 1: SITE INFORMATION
I.I Property Address: j �r� 1.2 Assessors Nlap& Parcel Numbers
/A 9�°g /�ovhotrri _
1.In Is this an accepted street?yes x/ no \lop Nunhvr Parcel Numhcr
k 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'n+posed Use Lot Area(sq II) Fronlage(11)
1.5 Building Setbacks III)
Front Yard Side Yams Rear Yard
Required Provided Required Providvd Required Provided
1.6 Water Supply:(M.G.I.c. 40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Ihtbiic❑ Private❑ Zone: _ Outside Flood-Lune? Municipal O On site disposal s)stem O
Check il' yesO
SECTION2. PROPERTY OWNERSHIP'
2.1 Owner'of Record:
v L. Avo-vtA'✓ 'C or
Nano(Print) g City,State.ZIP
/45iT 7V5'f!t 50
Nu.and Street relephone F.mail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building O Owner-Occupied O 1 Repairs(s)g I Alteration(s) Cl Addition ❑
Deawlilion ❑ I Accessory Bldg.Cl I Number of Units Other Cl Specily:
Briel Description of Proposed Work-:
t
SECTION a: ESTINI.ATED CONSTRUCTION COSTS
Itvill Estimated Costs: OMclal Use Only
ILahor and \laterialsl
1. Building S ` O 1. Building Permit Fee: S Indicate hu%v fee Is determined:
❑Standard City Tussn Application Fee
2. 1:1vctrical S
❑Total Project Cost'(Item 6).x multiplier _. x
1 I'hunhing S '. Other Fees: S_
J. MQOI nlicai ill\ \(•1 S List:
seioni S r+nal .\II Fees: S_
ChvcA No. ( hcck Allio un: C ,Inh \m+nW:
t+ Total Project Cost: S l4-di%n ❑ P;iid in Full C] Owst:nding lial.nce Due:
SECA ION S: ('ONSTRIICTION SFRVICIKS
5.1 ('unstructiun Supervisur License 1('SI.I
../___ � ._...____ IlccnseNunlher IyliratiauDale
N. w of*(Sl. I lolder
Jl
_l0 1 ' �� u Ct,�� S � PCIks�ri lion
No an,lsircvt '
U II hlrestrielrJ I Duddin s-.P to 15-1 o al.
li Rc+lricleJ Ik? I .unil Dllellin
l'igifoa n,\I;Ife LIP \I \la;un
RC I Rmiling Uncrin
..._. A'S Window.wJ Sidin
SF SuliJ Fuel llurning Appliunces
9?fff3sz�z lg �q (° /�0�. I Ilnsafatinn
hon fete e 1'Inail aJJrcS.Y U Dmnaliti'In
5.2 Registered Home Improvement Contractor(HIC) }
///% T 7 I IIC ICegistruliun Number I:Npiruliun Dalc
I IIC Company Name or I II ' R.gi)'lrmlt ,: Al
Nu. ug SUX1 s� /�y���?��� l:muil address
L M Hv�ct 7
Ci /Town.State,ZIP rele hung
SECTION 6:WORKERS' OM1IPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 .......... 0 No...........
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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 Omicir s N ne(Electronic Signature) Dale
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering fay name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application its true and accurate to the best of my knowledge and understanding.
I(l C4cr fir x f d' e'�'I�1Gj'hL/� (9 jZ
I'rinl Uw ner's ar \udnlrireJ.\gent'+Nunw I lilectrunie.Signature) Dw
NOTES:
I. .\n Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered eunirwor
(nut registered in the Hume Improvement Contractor I HIC) Program). will no have access to the arbitration
program or guaranty fund under M.G.L. c. I11A. Other impunaot information on the HIC Program can be Inund at
Neel,% 11,.11. „„ v 1 Information on the Construction Supervisor License can be found at,,w'% w-; ", %
2. \\lien substanlial wurk is planned, provide the infuriation below'
row (lour area(sy. 11.) - 1 including garage, finished basement attics. decks or porch
Grass liv ing area I sq. it I .._ _... _... . .- Habitable room count ._ -. ... .
' \wnherol'lireplaccs Numherofhcdrlunls
\umherofhmhruunts - _ - _ - _ --- \'umbcrufhAt'haths .
f�11e of hell lllg S%,Io n \Ill ilber ol'Jecks parches
l
l\he I dPallpg i\Ueln I`II:Iavcd Opoll
..1',d.11 'r U�eGl $,I llafl' I'Oga ge 11111\ he i11h�III111CJ IUf •.I'ULII i
C['I'Y OF S:�E.�t, NWSACHt;SE"ITS
s UL'ILml; DEP.gt TNLF—NT
120 \' ASHNGTON STREET, 3"'FLOOR
TEL 978 745-9595
7 i0-98.1b
KI M B ERLEY D IUSCO L L THoSL\s ST.Mum
%LRYOR
DIQECTOROF P1:9LIC PROPERTY/OI:RDIXC,COSt31IS5IUNER
Workers' Compensation Insurance AlTidavit: Builders/Contractorv/Electrict•rns/Plumbers
it s illeant information Please Print Leaihl �L
V;Imelllu.tiiw:,�<)rl;.ttitsatiunlnilivitlual):�'rp�N•y,�,�,�%1���h�N �"LL'e��J�a�/ Gj.�
f{ Address: m// \
a
city/state/zip: 410; r / `PhoneN: 91, 79
'%re yttu an employer?Check the appropriate boss 'type of project(required):
I.❑ 1 am a employer wide 4. ❑ I an a guneral contractor and I S. ❑Now construction
employees(till and/or part-time).* have hired the sub-contractors
2. lama sole proprietor or partner- listed on the attached shed. I 7, ❑ Remodeling
.hip and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. Building addition
[No workers'.comp. insurance 5. C] We are a corporation and its
required.] officers have dxercised their to.[] Electrical ropsirs or additions
3.❑ I an a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers'cutup. C. 152, 11(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.(No workers' 13.[]Other
curt insurance rcquimd.j
-nay appllure dwt chwka but A cowl Aw ntl out thv tv-etiue below showing?hoir vakm'campenudun pulley mdumadon.
'I L.nvown ns who,uhniii this affidavit Indlwing they.m doing all%writ and than him oulride eonlraetors muq ruhmil a tine mrldavil Indleating utch.
:c.,m neon that cMik this box meet onachod an.Wdeeutud.hatl shuwive the time*or the rub.urtuaetare and shalt workers,comp.policy Inromudoa.
l am on surpluyrr/hat is pruvialnX workers'cumparradun insurance for my employees. Below ls the pollcy and job site
infurrrrullan.
In,umnce Uontpany.Name _....-..
Policy 4 or Self-ire. Lie. 0: Expiration Dote:
Job Site Address: City/Statet2'ip: '
\lNeb a copy of the workers' componsatloo pulley declaration page(showing the policy number and explradon data).
F iiluru to wcurc euvdrago m required under.Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
rive up to il.500.00 andlor one-year imprisnnment,as well as civil penalties in the form of is STOP WORK ORDER and aline
` �- of up to i_'S0.00 a Jay against dtt violator. Ile advised that a copy of this,tmcment may be furwardcd to the 011icd of
Ltve,tigutions ol'tha DIA fur insurance coverage veritiealiun.
Ida/rrrrby crrd,(y under the pains alga penulllas✓f p•rjury char the in�unnurlun pro videdd above it sue ad correct,
IV
I'ha1c,l (`
U//idol uee u,dy. Da nor'vrite in thin area, ro he cu?uplerca by riry ur rotin.ej/lria!
City or Tovn:_ I'crmitil.lecnee 4___.
h,oio; Aiii1varily (circla tine):
L hoard of Ilealih !. IluilJlmg 0eliaronent 1. Cilyi ,ovii Clerk 1, E.Nctric 11 (mvetior i, I'lumhinv Iutpector
0. ILhar
i.t,t 0,rUtn: hhmw 1:
CITY OF S.l -&Nf, Akss.,C iusE-m
JLUXNG Oermt-nLE.rT
I 'O WASHNGTON SrXW. J 4 FtOCIt
r2L k973) 143.959J
KIMSFRLSY OXISCOLL F•kx(973) 1449"
MAYOA Mc..%I u ST.PMXJLS
OIxB CltOPPLBUCPRCPIItTy/at:MDNCCa.%OIISstONES
Can3tructioi3 Debris 013pos21 Affidavit
' (required for all demolition and renovation work)
fn accordance with the sixth edition of the State Building Code, 730 C��1R section 111.J
Debris, and the provisions of MGL o 40, 3 54;
Building Permit At is issued with the condition that the debris resulting from
1his
$ I JOA.work shall be disposcd of in a pro
1 1perly licemed wrote disposal facility as deRncd by NIGL c
The debris will be transported by:
15 ASN6S4/
(flame of hauler)
The debris will be disposed of in
--i9x-CzD a ar r 1Iyl ��_
(rddrafr offi,il,1y)
vtn�mro of permit ippliant