8 NAPLES RD - BUILDING INSPECTION (2) The Commonwealth of\4assachusetts
f � U
. Board of Building Regulations and Standards CITY OF
SA EM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only.
Building Permit Number. ; Date Applied
ARl-
Building Official(Print Name) Signature - Date
SECTION L SITE INFORMATION
Llgaperty Address: 1.2 Assessors Map& Parcel Numbers
Qaoies
1.la 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(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Requtred Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesCl
SECTION 2:, PROPERTY'OWNERSHIPL
2.k-Qaa�rtofR�e`c'6R, I'PM mea of97U
N e(Print) City,State,ZIP
9 A)a�e5 {
No. and Street , Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only,
Labor and Materials
1. Building $ �� d e I. Building Permit Fee:S` Indicate how fee is determined:
Q Standard.Cityfrown Application Fee
2. Electrical $ 13'rotalProjectCost3(Item.6)xmultiplier x
3. Plumbing S 2. Other Fees: 3
1. Mechanical (11V:\C) I S List:
i. Mechanical (Fir,: S - _
Sn � Cession) _ _ 'Coral :\II Fees: S_
Clieck No. Check Anwunt: Cash AuwuuC
Tutal Project Cult $ Q�
i ded.00 ❑ Paid aul in Pull Cl Outstanding 13al;mco Uu:.: ._--
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) FOOD--
License Number E.epirati i Date
:mt Ne ofCSL I lokler c
,�`�.y1,p List CSL Type(sea below) ra
0?TSL...1—"� C� Type - Description
No. and Street
` (} U Unrestricted Buildin s u to 35,000 cu. tt.
S Ale", (Yl 0 \ o R Restricted 1&2Fumil Dwellin
City/"Cown, State,ZIP 1\4 (•1asonr
RC Roofing Covering
WS Window and Siding
'A ---�—• f SF Solid Fuel Burning Appliances
q7F-1Ka3- y7/r� UCt—M�t.�d Viol/lee+ \(� Insulation
rcie hone Email address D I Demolition
51 Registered Home Improrvement Contractor(H1C) r 3 9b 30
-(t " p 0 HIC Registration Number Expiration Date
I I IC Cum an N� ne or ll IC R•gistrmu Name
�p Y
No.aryl:1 Sret R r i Email address
fte T
City/Town, State, ZIP rele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. t52. § 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 .......... No ...........
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDINGPERMIT
I, as Owner of the subject property,hereby authorize r M D//L>�t �i h e Q f p2
to act on my behalf, in all matters relative to work authorized by this building permit application.
�Gtw S/ S oZ i -I J
Date
Printrint OwnerTunt(Electronic Signature)
SECTION 7h: 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.
Print Owner's or Authorized A.-ent's Name(Elect unit Signature) Dam
NOTES:
I. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty Cund under\LO.L, c. 112A. Other important information on the HIC Program can be round at
www mass.',ovoca Information on the Construction Supervisor License can be found at www.mass.. o��idL
? When substantial work is planned,provide the information below:
Tot i tloor area(sq. It) � CZo�6_^ /60. including garage, finished bascment/attics, decks or porch)
irro;; living:uca(sq. tt.) -- habitable room count
Number of fireplaces" Number of bedrooms
Number otbathroom; Numberofhalf'baths _----- --
fcpe of heating sy;tun . .. ",-- ---_.-- Number of decks'porches _
I)paofeoolin� ;yaem "-- -"_ .— Enclosed-- _ t-)pen _ __-_-----
1 111"joct squ.ua he siih;ntutad t:)t I'rojeCt ('o,t'•
w L
CITY OF S:UE,%fit NWsi1cffusETTS
OULMING DEPAATMF_NT
120 WASHNGTON STREET, 3se FLOOZ
TEL (978) 745.9595
F.ke(978) 7•i0-9844
UJII)FRI RY DRISCOLL
MAYO q THostu ST.Pmus
DIII.ECTOltOF PUBLIC PROPERTY/BUILONG CONNISSIONER
Workers' Compensation insurance AfTidavit: Builders/Contractors/Electr(eians/Plumben
•lnnlicant information Pease Print Legibly
Nam:tousi,vifnor inlrirlamIndivldual): J t /(>1 O I k7 W eel-F
Address: oC �Q1P.4 P2 C_T"
City/StateMP: AIr'1 /!I ��� 70 phone ??Y— �a2 3 ��/J
F1.
you an employer'!Check the appropriate best 'type of project(required):
1 am a employer with 4. 0 1 am a geneal contractor and 1 6. 0 Now construction
nyea(full and/or pact-Lima).• have hired the sulacontractars
Iam a sole praprictor ur ptusnar- listed on the attachedsheet t L ❑Remodeling
+hipand have no employees These subcontractors have & 0Demolition
working for me in anycapacity. workers'comp.Insurance. 9. 0 Building addition
(Noworkers'comp, insurance 5. 0 We are a corporation and is
required.)
ofRcen have exercised shalt 10.0Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myseiL(No workers'camp. c. 152,§1(4),and we have no 12.0 Raof
r employees.[Noworkers, lJ. re its
insurancorequired.1
camp.imuraneerequired.) ❑Other Q q
•\n o Ilunt that dhwkr boarI must ilsu nil out the scerim below diewln Ihelr"Jam.con a-PR
Y Pp a penadun policy inlLlmatlan.
r I hvnvuwnwe who tdmtit this affidavit indicating they am doing all wart and then him eunide cantmeteta matt submit a now alltdavil tndfoting suck
!Conitauaors that Ousk this boa mutt snached m addfbunal sbat showing the none of Ira neba'Onifietare and their wurkero'comp policy Inrwmneon.
/um art surplayn that lr prmvld/nR rvarkera'rompentadon lusarence jot'my stop/uyarrl Below/s fheirallry mid fah slfi
iajonrtuAon
Insurance Company Name. (` 2 +-O U Nd P 2 W er 1`O R S f u S �a
policy 4 or SclGius. Lie. a: 6, e,303 -0iq 7N77—/—/1 ESpimtion Data•_a
Job Slits Address: xJ9�IPS �'F CilylState/2ip: 3,01FJ-st en 0—
Attach 2 copy of the workers'compensation policy daclaratlon page(showing the policy number and expiration date).
Failure to secure coverage as required undur.Sacilon 23A oe*YIGL c. 152 can lead to the imposition of criminal penalties of s
tine up to S1,500.00 untVor one-year imprisonment,as well as civil penalties is the form of a STOP WORK ORDER and it line
of up to 5250.00 a day against ilia vialatce. Ile advfred that a copy of thisslatament may be t'orwirdcd to the OhTuct of
Investigutiwts of that n IA for i nsurmices eovaraga verilicaliun.
/da hdreby cvr/fj made list pules uud ruvlNes u1parJury r/wt the lnjunnudd r pravided above is,tree uud correct
ii.,rmrtlre: a[•u�'j�'1- I)utu• oZ3^��
i U/i7,01 uas wily. Oa slat wrlle in t/dr area,to be eautpletad by city ar tawtr n/Jir"
i
City Of l'uwnt .- _ PL`fmit/1.Iccnse:y
IuuloX,\Whurily(circle one): _ -
1. Iloard of Itealih I. Iluihfinq mpartwew I.Cilylrmvn Clerk I. b'.feetrieal fntpectur i. I'Iaotbinil Lispector
u.0111ur ._
Contact Nrvnit- _. ... _. 1'hana:l: -
v
Y. CITY OF S�1C.Em2 LtiL1S&. CHUSETTS
Bt:tLOLYG DEPAIR . ZNT
1?0 WASHNGTO N STREET, 31°FLOOtt
s%~ T -L (978) 743-9595
(<f1(MUEY DRLISCOLL F.U<(973) 7.10-9344
UYO,i T�10.%&U ST.PIEms
Dt2ECT"OF PCOUC PROPEM/BCJLDLYG CONNISSIONEA
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 CZWR section l l 1.5
Debris, and the provisions of Ib1GL a 40, S 54;
Building Permit fr 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 WGL o
I11. S 150A.
The debris will be transported by:
Imo/h,tf 4��FQ1�2
(name(it'hauler)
The debris will be disposed of in
� (nama ut'tacility)
(adJras.t ur tatility)
signature of ermit applicant
5 ��3�13