76 MOFFATT RD - BUILDING INSPECTION (2) �• f� V�h ' fJ J
zG ll
The Commonwealth of Massachusetts It
I Board of Building Regulations and Standards CITY V M Massachusetts State Building Code,780 CMR SAMar
Revised Mar
t Building Permit Application To Construct,Repair,Renovate Or De 16 ish a
One-or Two-Family Dwelling
This Section For OfE6 se Only
i
Building Permit Number: - t pplied:
Building Official(Print Name) ' Si Date
SECTION 1:ATFPWORMATION
1.1./pro e ,rA-d1d(ess: 1.2 Assessors Map&Parcel Numbers
r
Lin Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard - Side Yards . ' Rear Yard
Required, Provided Required , Provided Required. Provided
1.6 Water apply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage System:
Zone: _ Outride Flood2
Public Private❑ Check if yesl� Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP' I'
2.1 Owner of Reco��d: � l
%e/ate P 7150>' 7� h1n 7L O
Name(Print) city,State,ZIP
>6 1y/o F t R 9»->y9-y�6i
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply)
New Construction❑ Existing Building V1 Owner-Occupied Repairs(,) ❑ 1 Alteration(,) 01 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify: - -
Brief Description of Proposed Work: K c an f-e.Vaglel - t/ ;'� y, ,�" c
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item � abo'rJand Materials Official Use Only
1.Building $ 3/p00,C d 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ - ❑Standard City/Town Application Fee -.
S O 0 0,00 ❑Total Project Coal'(Item 6)x multiplier x
3.Plumbing $ 0 0 0 RJOr 2. Other Fees: $ ..
4.Mechanical (HVAC) $ List:
S.Mechanical (Five $ _ 1,, _
Suppression) "' '- Total All Fees:$
_ Check No._Check Amount: Cash Amount:_
6.Total Project Cost: $ O p ❑Paid in Full ❑Outstanding Balance Due:.
i
7
t
_. SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) '
p!-ay�l (jgaadlt//Ij License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
.No.and Street - d T - Description
Unrestricted(Buildings up to 35,000 cu.ft.
Restricted 1&2 Family Dwelling
Ci %town,-State,ZIP M Masonry
RC Roofing Covering
InF6=o WS window and Siding
/ SF Solid Fuel Homing Appliances
41P-3-W6S I 1 Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Com an Nan o HIC Registrant Name
No.and Street Email address
O� f7Ff y�3. W"
critffrovVit,State,ZIP Telephone -
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workets Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu of the building permit
Signed Affidavit Attached? Yes.......... No.:....:....❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR AP/PLIES FOR/BUILDING PERMIT
I,as Owner of the subject property,hereby authorize /G NiL rr/ (7c�d�-✓/N/
to act on my behalf,in all matters relative to work authorized by this building permit application.
to
Pridi Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION -
By entering my time below,I.hereby attest under the pains and penalties of perjury that all of the information
contained 's application i1.true and accurate to the best of my knowledge and understanding. .
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES;
1. An Owner who obtains a building permit to do his/her own work,or an owner who hives an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dos
1 When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemenUattics,decks or porch)
Gross living area(sq.fL) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths -
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost" '
&lee�ianrrimvt�ova�L�o/.�P/�adl�c�mae/lJ
Office of Consumer Affairs&Business Regulation f3j License or registration valid for indivtdul use only
, OME IMPROVEMENT CONTRACTOR I before the expiration date. if found return to
egistration 105029 Type:, . 1 Office of Consumer Affairs and Business Regulation
_
10 Park Plaza-Suite 5170
xpiration 7M6/2014. Individual
_. _ _ ' Boston,MA 02116
t MICHAEL F.GOODWIN JR -
Michael Goodwin Jr.`
7 HOLT.RD.
EPPING,NH_03042 - Undersecretary Not valid without signature
f.
*- ♦lassachusetts- Department of Public Safer'A
Board of Buildit Rc�ulations and St lWars
Construction Supervisor License
License: CS 81670
MICHAEL F GOODWIN
,I
HOL
7 PIN --
EPPING, NH 03042
Expiration: 8/&2013
(lnnmis.ioner Tt#: 2951
i CITY OF S.U.EL`f, I/LASSACHLSETTS
BuILDIING DEP\RnMNT
• + 130 W.stsHiNGTON STREET,3'n FLOOR _
'ILL(978)745-9595
FAX(978)740.9846
KIJIBERIEY DRISCOLL
MAYOR I1tOMAs ST.Pm1eR8
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLXG CO%L%aSSIONER
Yorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name IBusincss,O�rrganimioNlndivlIidu;l): //�s"'�yL���ia.cl-✓ih
Address: 7�// /V d
City/State/Zip: 4;W4 �y O3oJ— Phone It: 91 !?
\re u an employer?Check the appropriate box: Type of project(required):
1.WLJ 1 am a employer with 3 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the subcontractors 6. ❑N construc[ion
2.❑ 1 am a sole proprietor or partner- listed on the attached sheeL t 7. Remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance, q, Q Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13❑Other
comp.insurance required.]
•Any apphernt that chucks box ill must also Ell sun the sectim below Growing then worker'compensation puliey infuneation.
r I Inmeuwreis who submit atis affldmit indicating they are doing all work and they hire mrtside contmcmra mesa submit a new affidavit indie Ling suds.
:Ca tram that check this box mwn anoched on addiiioml sheet showing We nano of the subwmrdors and then worker'comp.policy infermouon.
1 am an employer that is providing workers'compensation insarancefar,my employees, Below is the policy and Job site
information.
Insurance Company
Policy k ur Self-ins.Lie.M jlwc6 015'175a1 Expiration Dater /s"�
Job Site Address: Z6 I i16 if&/` R J City/State/Zip: .5g/z%1h
Attach a copy of the workers'compensation policy declaration page(showing the polity number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby cerrify under the pains and p�enahiles of perjury that the hiformadon provided above G true and correctt.
Sitmaitire; "'ice!/ Data:
Phone
Ojjcial use only. Do not write in dris areq to be completed by city or town ofiriaL
City or Town: PermittLicense M
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone It:
CITY OF S.UX. I, TN'LkSSACHUSETTS
Btiu.DLItG DEP1RT.Nm,4T
P 130 WASHNGTON STREET, 3�FLOOR
TEL. (978)745-9595
FAx(978) 740-9846
��tgFRT i+Y DRISCOLL
MAYOR THomm ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%ffssIONER
Construction Debris Disposal Affidavit
(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 c 40, S 54;
Building Permit# 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 MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
-The debris will be disposed of in
(name of facility)
5-1 `
(address of facility)
signature of permit applicant
date
debri. tffdm
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