81 MOFFATT RD - BUILDING INSPECTION i
r Tr-a) - ! z— (o 5 CAS L
The Commonwealth of Massachusetts
Board of Building Regulations and Standards REC 1VE y
y; Massachusetts State Building Code, 780 CMR INSPECTI AL S, YAI
Revised Nlar 2011
Building Permit Application To Construct, Repair, Renovate Or De sh a, 3 A & 03
One-or Two-Family Dwelling 11I1� JU11
This Section For Official Use Only
Building Permit Number: Date Applied: .�_�.1.
Building Official(['tint N:une) Signature �t Uato
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
—%I I"a FF^:+ 9-4
1.1 a Is this an accepted street?yes jt no Map Number P:acel Number
1.3 Zoning Information: IA Property Dimensions:
to Sly
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required - Provided
to, 1 30`
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Pt Private❑ Zone: _ Outside Flood Zone?
Check iryes Municipal On site disposal system El
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
C)Cew Arv%4A S-06-tm mek O14'10
Name(Print) City,Stale,ZIP
SI M0 V;a,-"-- 1-1q 0-$927 e It's
�1A /�PGcJ
—1J—ss G 00
Na. and Street Telephone Emuil Address rye
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Cl Existing Building X- I Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition id Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Spcciry:
Brief DescriptionofProposedWork': Dento hao%iw*" ua tts 4 frl A + flneK pooet% !7tA. _
F W►vnG�t�S M 1 1 L✓(, !S Mm g t- ISfM>•.'n.l w.�t F. __dt ar �_1-b �•cJ�}n�._
Wew P4 %SbIC F+>-F ow C ?in?pames%
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and iblaterials Official Use Only
I. Building S 16S 0 Q I. Building Permit Fce: S Indicate how fee is determined:
2. Electrical $ -g O O
❑Standard City/Town Application Fee❑Total Project Cost''(Item 6)x multiplier x
1. Plumbing S 2. Other Fees: $
4. ibtechanical (FIVAC) S List: a�
i. iblechanical (Fire
Su) ression) S Total All Fees:S
Check No.___Check Amount: _ Cash Amount:
(,. '1'utal Project Cost: $ 9 ,3 OO ❑ Paid in Full ❑Outstanding Balance Due: --
dl�f�- 117-� ; Kra-tu5o �0 ( �
C''w
SECTION 5: CONSTRUCTION SERVICES
5.1 ConStr,uction,Supervisor License(CSL) CS- 01-M3 5 i.{—
License Number EsZOlS
iration Date
P
Name of CSL Holder V
n List CSL"I'ypc(see below)
r ., e.i
Z. gAu ubYlJ ii OrU6 Type Description
No.and Street-�T
U Unrestricted(Buildings up to 35,000 cu. ft.)
5A(GYYt /YLA O tT1 d R Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
97 S6 ?-0 131(6 Ogn0.Qo55 SR�° °�°( GON1 t Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or IIIC Registrant Name
No.and Street Email address
Ci[ frown,State,ZIP 'Felt hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 .......... 9 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize 04✓N A K-mSS T R
to act on my behalf, in all matters relative to work authorized by this building permit application.
Drt=w Af" OkA S- 3o- I'f
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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.
_ Noe, ASS 3'R S
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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 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.nmss.zov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) 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. "feud Project Square Footage"may be substituted for"Total Project Cost'
CITY OF S.1LE�I, ANsSACHUSETTS
t
BULMING DEPARTNLF-NT
(_'O WASHLNGTON STREET, 3aa FLOOR
TEI.- (978) 745-9S95
Nx(978) 740-9846
KINIBEILLEY DRISCOLL
tiLAYOR TriOhtAS ST.PtERRE
Dip.FcToR OF PUBLIC PROPERTY/BCILDING COXLAMTONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumhers
Alntlicant information (� (j Please Print Legibly
ihly
VeinL'(flusinassOrganita:iom'Individua4: \. arto- „Oss —� {L
Address: 2 t yilgt,,J Ave
City/State/Zip: 'Sort-M MO, 00110 Phone M:_ Qtl-i—'ZGS -1376
Are you an employer?Check the appropriate boa: 'type of project(required):
1.El I am a employer with 4. 0 I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the subcontractors
2.X1 ran a sole proprietor or partner- listed on the attached sheet. t 7• Remodeling
ship and have no employees These sub-contractors have B. ❑ Demolition
working tier me in any capacity. workers'camp. insurance. o) pudding addition
(No workers'comp. insurance 5. 0 We are a corporation mid 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' camp. C. 152, §1(4),and we have no 12.WRoof repairs
insurance required.) } employees. (No workers' j},�] Other
cmnp. insurance required.)
-An m n t upplicaun m checks but II ust also rill out th bd e section ow Show a
ing their workers'compention policy inii,rma[ion.
'I L.mcowlxn whu submit this atHeLinvit indicating Ihcy am doing all work and Ihm him outside contractors mint Submit'new Mdavit indicating such.
Cnnmaun that cheek Ibis box meat aoachal an addiliuwl eheal showing Ilx mmruc of the Subaonlriclon and their workers'comp.policy intia motion.
l ant can entpluyer that it providing workers'compensatan in.urancer for my emplayees. Below is the policy and fah,sire
lirj(rllllallan.
Insurance Company Nmne: _ __-___
Policy it or Sclf-ins. Lie. H: Expiration Date:
Jub Site Address: City/state/Zip:
,Attach a Copy of the workers' compensation pulley declaration page(shosving the policy 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
fine tip to S1,500.00 and/or one-year imprisonment,as well as civil penalties in(he form of a STOP WORK ORDER and a line
of up in S230.00 a day against Ilse violalor. Be advised that a copy of this statement may be forwarded to the Office of
Ineestigatiuns ul'ihe DIA for insurance covcroge verification,
/do hereby cerrij wider a pains and penuit/es of perjury that the iufunnufiwt provided ubuve is true and correct.
si•_II,It re Date 5-30— J e(
Phone l �(7 X-�65 -737G
Of/iciul use only. Ou not write in this area, to be completed by city or town ofjlciuf
Cirynr'I'uern: _.--. .__ Pcrmitif.lccnsct$
issutng,luthurily(circle one): -- — _—
l. Board of llcallh L Building Department .i.CiiylrownClerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact I'c non:_. _ _ _ __ Phanc M:
CITY OF S�1LE1I, Axs&kCHUSETTS
BUIMLNG DUAR-110NT
120 WASHLNGTON STREET, 1'0 FLOOR
TEL (978) 745-9595
F,ux(978) 7-W-9843
KIJtBEItI�Y DRISCOLL
,bLm.L TilOSLi4 ST.PIERR$
O(RECTOR OF PUBLIC PROP ERTY/H C MDLNG COJO nSSION ER
Construction Debris Disposal A tldavit
(required for all demolition and renovation work)
In accordance with the sixdl edition Of the State Building Code, 730 CMR section l 11.5
Debris, aid the provisions of rbIQL c 40, S 54;
Building Permit Jk is issued with the condition that the debris resulting from
this work shall be
lll, S ISOA. disposed of in a properly licensed waste disposal facility as defined by r1vlGL c
The debris will be transported by:
y
y N0X+%N 9,ClE Ca CNL.
(name ut'hauler)
Tile debris will be disposed of in
(nanteoeraedity) —�
_I�LS_..,a�, rzsce tf Ka1 5alew� .Mo.
( dJres.c of taciIity)
signature of ermit applicant
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