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The Commonwealth of Massachusetts CEI
° Board of Building Regulations and Standards 7CEP F
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hh Massachusetts State Building Code,780 CMR INSPECT
ICES
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demo M TE 19 A 4- 23
One-or Two-Family Dwelling
This Section For Official Use Only '
Building Permit Number: '' Date Appli
1 Building Official(Print Name) Signature Date
°' " ` ` SECTION 1:SITE INFORMATION
. 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
L l a Is this an accepted street?yes_ no Map Number Parcel Number
1 1.3 Zoning Information: 1.4 Properly Dimensions:
Zoning District - Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yazd - ' a Side Yards Rear Yard
Required 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:
Zone: Outside Flood Zone?
Public❑ Private❑ . • Check if yes❑ - Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSIIIPt
-
2.1.Owner1 of Record:
1—ref er 'gl< S'[� . " d 117 V .
Name(Print) City,State,ZIP
;- /t/. P: f� �I j I l -307 - 10fl
No.and Street '- Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR)e(check all that apply)
New Construction❑ FExisting Building❑ Owner-Occupied ❑ Repairs(s) Erl Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed WorO: 16
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e C.,i �e.v -J `/" .�Y " r 19 1-, reOl W ,1-c
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofcial Use Only
(Labor and Materials)
1.Building $ f 3 -�- U U 1.,Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/1 own Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ '
Suppression) Total All Fees:$
6.Total Pro'ect Cost: $ �S Check No. Check Amount: Cash Amount:
J , ❑Paid in Full_ ❑Outstanding Balance Due:
__ 'lodge
SECTION 5: CONSTRUCTION SERVICES „
5.1 Construction Supervisor License(CSL)
cs-e-7 913
6iaG( Fo� c�rpe� License Number Exp ation Date. _
Name of CSL Holder
,7 `f D6 N/ it
/Z I List CSL Type(see below) (1
No.
IIand Sire _ Type + Description ,
O /s-a( U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning.Appliances
Sdf- 71f /r�OU `��m ci 9�i . Co r. I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
U9H70
C (o n :a ( < a k.-,,j HIC Registration Number E piia'on Date
HIC Company Name or HIC Registrant,Name - (/
a` llk.;h S'+ - "ATO4G/n q9, . c�
No.aa�Scree - - Email address
�6� iCv6
City/Town,State,ZIP Telephone
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..........0,1' 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 authorizeto act on my behalf,in all matters relative to work authorized by this building permit application.
f c � ^ L
JA901C✓4 C� 15M ry lP ZO/J
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 ccurate to the best of my knowledge and understanding.
Print Owner's 9pituthorized 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 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.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/atiics,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. "Total Project Square Footage"may be substituted for"Total Project Cost"
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CITY OF S. .&M, NLASSACHUSETTS
B1:IIDINIG DEP.kwniENT
• 120 WASHINGTON STREET, P FLOOR
oT TEL (978)745-9595
FAX(978) 740-9846
KI\fBF-RLEY DRISCOLL
MAYOR T1 oma ST.Pmm
DIRECTOR OF PCBuc PROPERTY/BUMDING CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / nq Please Print Le¢ibiv
Name(BusimssOrganizatioNlndividual): / -. (c, r ill. ,
Address: al
City/State/Zip: 1 roe -`E L /d s/ 6Phone#: So Pr -7317-9906
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
e+�ployees(full and/or part-time).* have hired the subcontractors
2. am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
(No workers'comp. insurance S. ❑ We are a corporation and its 10.❑Electrical sus or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I 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' MCI Other
comp.insurance required.]
•Any applicant that checks box#1 must also fill out the section below showing their wmkm'compensation polity miomtati m.
'I fnmeowrtm who submit this affi"t indicating they are doing all work and then hire outside eomrectors must submit a new affidavit indiaring such.
:Contrt,nors that check this box most anached an additional sheet showing the name of the sals em tmcters and their workers'comp.policy infamaum,
I am an employer that is providing workers'compensation Insurance for my employees. Below 1s the pollcy and Job site
!"formation.
Insurance Company dame:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing 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 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 S250.00 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.
[do hereby certify untie►th• n r maples of perjury that the information provided above is true and correct
Sitz t tr / Date:
Phone#: S OS- --73 �'��Qt7G
Official use only: Do not write in this urea,to be completed by city or town at f riaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#'
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CITY OF SM.&M, iNLkSSACHUSETTS
BUELDIING DEPkRTNIEN-r
8 130 WASHNGTON STREET, 3� FLOOR
TEL (978) 745-9595
FAX(978) 740-9M
KI,%IBERL.EY DRISCOLL
MAYOR T HomAs ST.Pmm
DIRECTOR OF FLUX PROPERTY/BUILDING COMMSIONER
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: L c I
(name of hauler)
The debris will be disposed of in :
(name of facility) / f/
(a d ess of facility)
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signature of perm applicant
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COLONIAL RESTORATIONS
Specializing in Structural Restoration/Repair
of Post&Beam Homes and Barns since 1981
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` Restorations
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26 Ma nSt
26 Man St -
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26 Main St. —Brookfield, MA 01506
(508) 867-7698—Home (508)867-4400—Office
wwwerl981.com email- info(7a crl981.com