5 N PINE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standarc�� RECEIVE CITY OF
Massachusetts State Building Code, 780 CI SPECTIONAL S RVICCALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Nl 1��a A 4' 23
n One-or Two-Family Dwelling
L�7 This Section For OfficiW Use Only
Building Permit Number: I Date pplied: -
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property A/dJd:,ress: 1.2 Assessors Map&Parcel Numbers
AA
1.1a 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
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHW
2.1 Owner'of Record:
c} , 9 e S a.-1 AA t 5 7 e
r'� c�._ a,v,
Name(Print) City,State,ZIP
+
No.and Street' Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : e ( .c l ' S ;It e , 1 ^1 ii ` Ipe
L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials)
1.Building $ P c7 S p O 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. . . Check Amount. Cash Amount
6.Total Project Cost: ❑Paid in Full ,, ❑Outstanding Balance Due:
SENT 3fL4 is
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) "
r cs - e7rYl7a a It
_T License Number Expiration Date
Name of CSL Holder
7 y List CSL Type(see below)
No.and Stre }" tC Type Description
H. A�J Z/n V� d / �a 1 U Unrestricted(Buildings u to 35,000 cu.ft.
i R Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
( SF Solid Fuel Burning Appliances
S-ok-7.35--/`-90G__ �n*a� C�- i9kI . CC,..t I' Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement,Contractor(HIC)
% 'G ��,'�
ton cil /L as l-�, q- `....s �r
HIC^^Compa/nJy�Name or C Registrant Name. HIC Registration Numb)er Expiration Date
d� lira :�. r � A iA(06
No. a Street a Email address
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 .......... ld' No...........E3
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_-T l V Ah+0ZU (PIZCEyt —C04o AAl, FSip�17 �5
to act on my behalf in all matters relative to work authorized by this building permit application.
ERt C, -b18r,gvJ,T
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'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..
If—
S�
e r Authorized Agent's Name(Electronic Signature) r 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(MC)Program),will nol 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
wD w.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.90v/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basementlattics,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"maybe substituted for"Total Project Cost"
w
CITY OF SM EM, 2V'L-kSSACHUSETTS
BUMDLNG DEPARTMENT
130 WASHINGTON STREET,3tD FLOOR
TEL (978)745-9595
FAX(978) 740-9846
IU\(BFRr s:Y DRISCOLL
MAYOR T HoMAs ST.Pwj=
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER
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
M 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
�4�'t't �A�i'F��TZ G✓YA 1 t61J
(name of facility)
Y1 _
Z :!�?wAVW'57ChIi °Zpft�+ Sa4-EOA, 0A d(01-70
(address of facility)
h �
i
f
u
gnature o ermit applicant
2 - 6 - � s
date
JcbrivlTAce
I
i CITY OF & .F.M. NIASSACHUSETTS
BUUZING DEPAK-nIENT
• 120 WASHINGTON STREET,3"FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KINIBE.RI.EY DRISCOLL
MAYOR THomm ST.Pmm
DIRECTOR OF PCBLIC PROPERTY/BL•II.DL*IG COM%USSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busins$,Organiration/Individ i): efe //e � ra
Address: 9 L A^ 't f a---
City/State/Zip: /,5/�11� o k f .If Icy 414 o tSU Phone #:_ QCS 73 r- F90-9
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(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 5. ❑ We are a corporation and its 10 El Electrical airs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I t.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12. Roof repairs
insurance required.)t employees.[No workers' l3.❑Other
comp.insurance required.)
•Any appliram that checks box el must also fill Out the section below slowing their worker'compensation policy informotion.
T I Inmeownen who submit this a@ldavit indicating they are doing all work and then hire outside contractors must submit a tow amdavit indkoling weR
:COmmr tors that check this box must avacled an additional shred showing the name of the sub•commus rs and their workers,comp.policy infmnation.
I am an employer that lr providing workers'compensation lnsarance for my emplayem Below Is the polley andM site
information.
Insurance Company Name:
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 flue
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
Investigulions of the DIA for insurance coverage verification.
I do hereby certify under d tpai, es of perjury that the information provided above is true and correct
•n t tre• Date• �P Ig t_r
Phone 7-?r— go G/
Official use only. Do not write in this area to be completed by city or town ofliciat
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person Phone#•
COLONIAL RESTORATIONS
Specializing in Structural Restoration/Repair
of Post& Beam Homes and Barns since 1981
ReStnratione d..•,..
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Pa.a1�n .,�,:m .'-- iaec�iiNt14a ( :.
Massachusetts-Department of Public Safety Massachusetts- `.. .-
�(Board of Building Regulations and Standards, Oepartmerd ofPabNc Safe".y
C t arm.S.prr or Board of Building R¢gulatrons and Standards
iii Ln:ense CS078132 Cnmtrotp.nSvpa r
4cenaee CSOd2865
i BBADBOIID OIj88
74 DOC Im.1.RK I Thom r0Creen
HOLLAND MA 0152 . 26 Mu.Slrtetg5+ 1 kT
Br.oHi Id MA OF506
Exievatmn 0 {�`,✓F'J
Commasloner. -0812V S i.(...li.Gx¢.",p1 .> ExPiratlon
Cmxnasioner - 05/3112016
-------------
tf fC usnm AOim&Barmen,RM lanan { � Office of AB &Baran Reg latt"
MEIMPROVEMENTCONTRACTOR E IMPROVEMENTCONTRACTOR
q a0mtrztlo¢ 1080]0 TYPe
egle odder: 10B<]0 t TyP°- xPIra Tan 1s811& 16 Pa.xrshp
ExPirehon:8tt8R01B' . SU'PMmentte nrilx- .
COLONIAL RESTORATIONS 3 COLONIAL RESTORATIONS
Thin.Y'
BRADFORO GREEN 3 26Main Green
26 Main St 26 Main 5t � r
Braokf 10,MA01506 U.d nemry. { Evookfed MA01506 Un6eruereury
i'
26 Main St. —Brookfield, MA 01506
(508) 867-7698—Rome (508)867-4400—Office
www.cr]981.com email- infona cr1981.com