91 MASON - BUILDING INSPECTION 67
- I'lie Colin of bl:usachuscns
Board of Building Regulations and Standards CI'1'1' OF
'i 'VLtssachusctts State Building Code,7SO C NIR SALE.M
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One-ur rit-w-F ini/r Otrr/linp
This Section For( ial Usc Onl
Building Permit Number: __ ate Applied:
Ihuldiny UI11cia1(Prinl Nwne) Signature [)ate
SECTION I:SITE INFORMATION
I.I Property AddresL7 1.2 Assessurs Map& Parcel Numbers
1.la Is this an acce teal street? 'es no M Map Nunsher I'urcal Numlxr
1.3 Zoning Information: 1.4 Property Dimensions,
Lonin DDistrict Proposed lJsa Lot Area(sit Ig frontaaa(10
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required 13rcvideJ
1.6 Water Supply:(M.O.I.d 40.§Sa) 1.7 Flood Zone Information: 1.111 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Lone?
Crack if es❑ Municipal❑ On site disposal s)stem ❑
2.1
SECTION I: PROPERTY OWNERSHIP-
caner-af Reeordt C�PEza� % o f g 7 U
N;una(Pnnt) T— L II).Slala,I.IP
cl / Al .
Re S
.and S�Imcl� P•ie one "
hrnurl Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteratlon(s) ❑ Addition ❑
Denwlition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Spccily:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
rent Estimated Costs:
(Labor and Materials) OMNI Use Only
I. Building S I. Building permit Fee: S Indicate how fee is determined:
'. lAwmal S ❑Standard City.Tosvn Application Fee
t I'lumhiny S ❑Total project Cuser(pent 6).1 multiplier
_. Other Fees: S_
J. \ MI'lltica( ill\ \('1 S List:
4 \(ah.mic.11 Ills -- ----- . . .
11upl.re.sionl S total .\IlFcas: s -- - _ .._ .. ._-. ._ . .
n I'mal Projec( Cu.,t: i 7 ?�`
�y� ✓ 0 Pdid in Full ClOmslanding Bal.mce Due:
sr.(A ION 5: ( ONS I'RlicriON SERVICFS
. --1 1,—/" /�011
S I 2Z��16-E
5.1 Supra isor License((S1 4P.P-o 0A.- 7 I D�1117
icenw Numbvr
pe I)cscriijtion
,,4yi0 Si=V it
c1l WU I
k,;—ilama.—sime.Till t,xvin Orlcrin
%incim .old sid il-I
SF Solid Foci liUming,Appliances Insulation
1jjajI;iuJrv,,s
Talc hone
-------�11 Contractor(1111C)
gred I cime mpr
Reg
TIFC—14VII-tration Number live Wien I me
N o
12 Naincor /C —
No. and Street /;2el .1 9-3
CI /Town.state,ZIP reivone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 153.1 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 E3 No...........(3
SECTION ';,a:OWNER AUTHORIZATION TO BE E6111111FEE'LEW WHEN
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 2111111cati011-
Data
SECTION b:OWNERt 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 a Ii curate cation is true and rate to heJ,\Cst of my knowledge and understanding.
PP
9�0741-s�—
ctronic Signature)
'r 7—' Dr ES, ,1n Owner x0o hires an unregistered Q01111"Iclor
n Owner who obtains a building permit to do his her own work,or
)nig Improvement Contractor(HIC) Program).will no have access to the arbitration
111101 registered in the Ht
program or guaranty loild under M.G.L.%:. 141A. Other important intiormation on the HIC Program can be round at
I Information an the Construction Supervisor License can be found at—%Ik 111J,1 !;t-\ "I"
information below:
nto substantial�%ork7s planned. piu4tde the in I'or I I I including gauge, flnished bascinciA.Ittics,decks or porch)
rotai floor area 114. 111 Habitable room count
Grosi I,%ingarea 114. It Ntilither ofbcdrooms
Number A 11,111 hailli
-,timhcrol ball'I'0011's st,111i,cr q'decks, Iiordwi
I,\pe of he-itiog i)item1:110o,cd
cd lilt ,I'oial Proiccl Cott"
$Ljthlrc 1:00I.We 11M\ I"!
CITY OF S.u.E.,N(9 AISS.ICHUSETTS
f31.'tLOLYG DEp.1RTlF.\t
I_'0 p.UJ40JCTON STREET, 1+4 FLppR
RL (973) 745.9591
.'U1c3EALfiY DRLSCOLL
AX(979) 1t4984d
,%CAYOA MO.VAJ sT.PMUA
DIREGT04 OP PLsLIC PR0PlR7Y/BCQ.0GYC C01p1(sstONElt
Construction Debris Disposal Alfidavit
(required for AM demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 190 CMR section 111.1
Debris, and the provisions of MGL a 40, 3 34;
Building Permit a is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by A4GL c
111, S 130A.
The debris will be transported by:
(name of haul#
/no
dddebriiss�wi ICI be disposed of in .-
v - iine,L %n
(nam*
of racety)
1 rddrtu of r�.d �y)
1
+ynamre of permit rpphtrnf
f 1
1;• C[ I l UN 5LEm JL1ss.\CHI5 E [TS
1 1 Ut:ILnlac DEPARrxE.�T
It
120 %V."HLNGTON STREET, 31D FLOOR
TM (979) 745.9595
Fli-I(979) 7$0.9844
1<1.%IDtRLEY DRJSCOLL
NLAY02 THONLU ST.Phase
DIRECTOa OF PUBLIC PQOPERTY/BUI DING CONNISiIONER
Workers' Compensation insurance r117idavit: Uuilden/Contractori/Electric(•rn.-jPlumbers
%nolleant information Please Print Legibly
V:InlCllhui'u.Burg,7nva/u/,�m�,Indivi/d/u,lU:_ l � f"")1 /A�n71 Y(
Addfexs:
City/State/Zip: Phone N: 2,2
ff — J
\re you'An employer'!Check the appropriate boatjn
'rype of prniett(required):
I.❑ 1 am a employer with _ _ ;. ❑ I am a general tlor and 1 S. Cj New construction
employees(Ifall and/or part-time).• have hired the stractars
2.❑ lain a sole proprietor or partner• listed on the attaheet. _ �• ❑Remodeling
ship and have no employees These subcontrhave I. C Demolition
working liar me in any capacity. workers'comp. nce 9, building addition
(No workers'comp. insurance 3. ❑ Wa ue a mgnrand itsrequired.( offIccrs have dxe their 10.❑Electrical repairs or additions
).0 Iran a homcuwner doing all work right orexdmptiuMOL 1 I.C]Plumbing repairs or additions
myself.(\o workers'sump. c. 152,1I(4),andave no 12. Roofrti sininsurancerequiied.il employees. [Nows' ), Olher
sump,insurance rd.);.\,iy Irplk:un dur.hw4a brat rt must IW oil nw 1ha'.aloe hulaw.hawina'bait vmee compenudun putky nnlrmaltoA
I h.nvuwrnv who whmil Ibis a1114vii indlcalne they in dsfne ill wart rnd'hen hire oatlida centncrem xnet mhmit a new allldavil fndicatine luck c 1m'maun that ch.et this hex meal inachud in 14dltiurad.heal nhuteine the mates at'he wbeunIMuirs...i thalr wnrters'ramp•pulley Inrwrru lan.
J urn an nnp/uyer that/a pruvld/nX Iv rkrn'cumpauar/un Ineurence%r my emp/uyers. Bduw is the polJoy undJub ills,
iulurllrurJnn.
In,urance Company Name:
Policy 4 or Self•im.�Lic. it: Expiration Data'
Jub Site Addrusr. &4/2, Cityisfuteizip: _
Attach a copy of the worker'coin panswiloo policy declaration page(Ihowing the polity number and eipindoa data).
I- liluru to wcuru euvdragd as required under Section 2JA o(MOL c. 152 can lead to the Imposilion ofcriminal penaltids of a
rir.e up to i 1,500.t10 and/or one-year imprknnmcn4 as well as civil penalties in this t'orm of o STOP WORK ORDER and a line
af'gl to i2J0.00 a day Igainst Ilia viula(Or. Ile advised that a copy of this,latement may be furwirdcd to the Oilics of
la veNigation.t„I tl'e n1A t)c insurance coveraga veriliealiun.
/Flu brrrby cerlil IJefile p r uls4 penahlr.r pe jury/hug,the inlluralurlun pro vidrd above it vui.ilia�currret.
UI/leis!n 1 e Truly, /lr nor�.-rirr in du:r:uro, m 50 completed$y riry ur/u r.nr•r/�Iriu(
City nr I'inrn: . .... i'crmilil.lceme 4
(•.ui a,+,.\ulhorily (tire la one): _—.�. ._ .__
I. ituard of I Italth !. Iiuildlrw I)ch.lrhncut 1, 1 Styl f"mn Clerk 1. (ifectrir ll (n„cet,
f, lhh<r I tr i. l h'�nhi n;; Inrpecr,lr
l'n nlncl I'rruu1° I'hgnc k .
�y__ PROPOSAL
CoDo
I
i
I Prnpo>al Submitted To: Io6 8
Address loh I_ocalion
91 ci son 3�_
Date Datc of Plans
�Phonc ii �yr �� �3 Fax# \ishitoct n
[ yVrpp by .nnt.sp _5t qu o- lntrtes for- I ___.� y-s a _-_ ��n . ��fM -1�ple
ijIIn�I ------ - - —1V---------- '-- l - t--l.f �� E
Approx . � S uc�� S h � e _ Ci �r 'II
3v cur _ -
'I
be _ n��aler
Wc propose hereby to furnish material and labor—complete in accordance wilt the ab vc specificatlon.c for the sum oi.
+ l 77 t. j
.`r,y} .3 O
with payments to be made as follows: Q D�f�o c 'j' O G o') nm(7
Any ahei Lion or devlslion fi'om abcve sp-ci5c.otions utvolvino culu oo.IS will R eGully submitie E -
br,exemnal only upon ' iticn order I will become m extra charge ovcl and �`gyc,\)
ihovc tile estimate. All tpreemenis contingent uponsn lkcs accitleni.s,nl delays
hoynnd our ccrntml. tc
Nolo-this proposal may be withdrawn by us Knot accepted within clays.
FT)I
ACCEPTANCE OF PROP ALe plices. sprclln nions and conditions are atisfacrory and alecerled. Yon a c authorized Io do the work v specified_ Paymonlx Slgnafilreade as outlined above
Acceptance:_ a. _ Signature
A-NCss 19 i Tassn