80 MEMORIAL DR - BUILDING INSPECTION (2) I'he Commonwealth of Massachusetts
y; '� Board of 1uilding Regulations and Standards CITY OF
It
d, Massachusetts State Building Cute. 780 CMR SALGAI
��� XdrisrJ.l her_'ill/
Building Permit Application To Construct. Repair. Renovate Or Dentolis a
One-ur Ttsv-Funrilt-Duelling
This Section For Official Use Only
Building Permit Number: Dat App ie
l" wr7RY�./ J72ZZ fir ` /
Building 011icial(Print Mum) Signal )ate
SECTION I:SITE INFORMATION
1.1 Property Address: r 1n�v�� 1.2 Assessors Map& Parcel Numbers
80 Mtt ,td�l I V
` I.I a Is this an acce led street?yes no Map NuniNr Parcel M uttter
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Imposed Use Lot Area(sq III Frontage Itl)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munici al❑ On site Jis
Check if 'es❑ P pusul system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1„Qwnert of Re ord•
Nmrte(Print) o city.State.ZIP
y mnU:wl N✓tr �L g36 2 3 4( lL
No.and Street Telephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Buildings Owner-Occupied 421� Repairs(s) 4 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specitry:
Brief Description ofProposed Work':
e v�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Rent Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S r(Doo 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard CityrTown Application Fee
i Plumbing S pp Total Project Costt(Item 6)x multiplier _ —_x
, pO�G. .-�, i❑ -
_. Other Fees: S
a. MQChanical III\'.\('1 S List:
5. \Icchunical 1Fire __---- -- --- .___--
1 S
Suttression) rotai All Fces: S_ --
Check No. _('heck Amount: C a)h \nwunt:
h. Total Project Cost: S �-. ❑Paid in Full 0 Outstanding 13a;utce Due:
SECTIONS: C'ONS'I'MicrION SERVICES
5.1 Construction Supervisor License(C'SL)
Lianic Nwnhcr F pira ion Date
Name Of(SI, I folder
I izl CS I.1)fk Isec below) _
z v
_Y,j �as � , r—..-ci 5 t�
No. ttld Strccl ----- v ---------- ----------- "I'� Description
U l InresIricted I IluiIdin�s ri nl 3 5,000 cu. 11.1
y -✓ �� ... . - R Reslric(cd 1 r? Emnlil y M%ellin
Cit.0"mil.Slmc.Llil .. wl klammiry
RC Rra,lin Coeerin
...—._ OD
S Window;md Siding
F Solid Fuel Burning Appliances
InsulationEmail uddress Demolition
S,2 Registered Home ImprovementfrCo,n/tt�ractor(HIC) ( 07 //�
lK-u - sit— IIIC'Regi stra tion Ni (ixliirilfion Date
IIIC Company Kane or IIIC•lictli.,trL71 Name
Cider LAw Oren\ r l (M-a .
Nu • 1 Sure! 01 �V 7� 17M Email address
Ci /Town,State, IP rcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c, 152. 4 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 ...........ffi- No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. as Owner of the subject property,hereby authorize RI ✓ J ( e `�
to a liters relative to work authorized by this building permit application.
Print U,wer's Name(Elect ni Signature) ate
nc
SECTION 7b:OWNERI 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 application is true and accurate to the best of my knowledge and understanding.
:�7
Prr 1l D, •r's or Aulhoritcd Agent's Nome IFleelnmie.Signaune) Date
NOTES:
1. An Owner who obtains a building permit to do his.her own work•or an owner who hires an unregistered cuntrictur
(nut registered in the Hun)e Improvement C untractor(HICI Program),will mr have access to the arbitration
program or guaruuy fund under NI.G.L. c. 142A.Other important information on the HIC Program can be fimnd of
11"t" % ,".1 Information on the Construction Supenisor License can be round at y, l,r it i
2. \Tlien substantial work is planned, provide(he information below:
rota) flour area(sy. n-) . ____""_I including garage• finished basement attics,decks or porch)
Grois living area iiy. IT.) - Habitable room count
\umber of lircplaces. _ Number ol'bedn,mns
Number ofhathrooms \umber ut'half halhi
I.N lie of heating iy item ._ Number of decks porches
i
I\pc of i0011114 i�itelll Enclosed
1. "I'ooal Prol"t Syuxe Footage"may he substituted Iur"rolal Project C'osf.
CITY OF S:U EN1, jL1S&kCHUSET B
BUILDING DEPART',&-NT
120 WASNLVGTON STREET, 3"FLOOR
T EL (978) 745-9595
FAA(978) 740-9846
Kimi3ERLEY DRISCOLL
NLAYOR T HONW ST.PlERM
DIRECTOR OF PUBLIC PROPERTY/BCILDINr,CO%LL%ilSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractorv/Electricians/Plumbers
Applicant Information Please Print Leoihl
.Name iflusiiwsa.Organiratiumindividual): (� Cpt_ Cp v
Address: LII C,CA, Tl�r
1
CitylStatc/Zip: D Phonelt: �� �2�{ �
Are you an employer?Check the appropriate box: Type of project(required):
I.0 I am a employer with 4. ❑ I tort a general contractor and 1I,
employees(full and/or part-time).* have hired the sub-contractor 6. ttt••❑ssn�� New construction
2. I am a sole proprietor or partner- listed on the attached sheet.I ?• tmadeliag
,hip and have no employees These sub-contractors have V.
C] emolition
working tier ma in any capacity. workers'comp.insurance 9, puikling addition
[No workers'comp. insurance J. 0 We are a corporation and its
required.[ officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.C] Roof repairs
insurance required.l t employees.(No workers' U.❑ Other
comp.insurance required.)
;Any applicant thatdus:kt box xl mutt alw fill uw the xatien halo,aAowing their w,ken',ompenwdon puliry infnmution.
I t.vneuwnas who suhmit Ihix atllMvis indicning they are doing all work and then hire uuttide contmcton meat mhmit a new amdarit inditaling ruck$'unnxton that chssk this box mud attached an additiurul.hml showing the name of the aubooniracwn and their worker•comp,policy infennatien.
fain(in eutpluyer shut is providing Ivorkers'cornpensatlan iararance jar my employees. Below/s the policy and Jab site
information.
Insurance Company Name:
Policy 4 or Self-ins. Lic. N: Expiration Date:
Job Site Address: CilyistatelZip:
Attacb a copy of the workers' compensation pulley declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A aCNIGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S250.00 A duy against die violator. 13e advised that a cupy of this.statement may h furwurdcd to the Of3ice of
6tvrsligatiuns ul'the DIA for insurance covcmgc verification.
1 du hereby c•rrti y under the puhrs rand Penalties wf perjury Ihat the iafurmwlou provided ub/'�,`'r i true uuJ correct.
q 13atw: 2/ 1r
I' a �1• fJ—+
i
0/1iriul use wily. Do sot rvrire in this area,to be completed by city or town V11cial I
City or Tuwa:
Issuing Authority (circle one):
I. Board of Ileallh -'. 13uildin; Department I.City/fawn Clerk 4. Electrical hispectur 5. Plumbing Inspector
6.Other
i
Contact Person: _ Phone N:
[
Information and Destructions
.massachuset s General Laws chapter 152'reyuires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as".-every person in the service of a tuduer 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 ajoini 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."
,IvIGL chapter 152, §25C(6)also states that"every state or local licensing agency shall wlthhold the Issuance or
renewal of a iicegse 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 rill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)nume(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. Sclf-insured companies should enter their
self-insurance license number on 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.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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 owrier 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.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
2cvi;cd 5-26-05
www.mass.gov/dia
CITY of SAL.ENf, AkSS:ICHL'SETTS
BCILDLVG OEP.IRTLE.VT
120 1V.UHNGTON STXM, ]1O FLOO4
T!L (978) 745-9599
KIAMERLEY DRLSCOE.L F.Vt(978) 740-984d
.ti1AYO)t TNO..%WST.P> AAA
DIAECTOt OP Pl8LZC PROPERTY/al MDL%4 C0\L\115S,O.S,
EX
Construction Debris Disposal Afttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code. 780 CMR section 1 l 1.
Debris, and the provisions of MGL c 40, S 54; S
Building Permit #
This work shall be dis is issued with the condition that the dcbris-resulting from
S I SOA. posed of in a properly licensed waste disposal facility as defincd by NIGL c
111,
The debris will be transported by,
(n una of hauler) d f
The debris will be disposed of in
(name of r��d+ty) U
(iddrrfi orFj,:ilily)
nk
iynatur fpermitipplicant