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30 NORTHEY ST - BUILDING INSPECTION (6) yb,Cb The Commonwealth of Massachusetts Board of Building Regulations and Standards RECEIVED TY OF Massachusetts State Building Code, Igo CPECTIONAL SE VIC�EM Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate�D�to}js�t a � 45 ' One- or Two-Family Dwelling JJtuJt� This Section For Official Use Only Building Permit Number: Date Applied: Budding Official(Print Name) D )� Signature Date SECTION 1: SITE INFORMATION 1.1 Property Addr ss - 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes_ no_ Map Number Parcel Number 1.3 Zoning Information: 11.4 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? Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'o�eacord: ,�f Name(Pnnt •�r�9 City,State,ZIP � / 0 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ S city: Brief Description of Proposed Work': I SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: abor and Materials Official Use Only 1. Building $ 0 Y7� 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees: $ 6. Total Project Cost: $ Check No. Check Amount: Cash Amount: .2o y� 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /0)- / &V �� License Number Expiration Date Name of CSL Hold(. List CSL Type(see below) No. and Street ' (� 6 Type Description r II /��//�• QC7� U Unrestricted uildin s u to 35 000 cu.ft. Cityflown,State,Z:P R Restricted 1&2 Famil Dwellin M Mason RC Roofin Coverin WS Window and Sidin r�11G�_ SF Solid Fuel Buming Appliances ._ I Insulation Tele hone Email address D Demolition 5.2 Regis er d F.o Ln rovement C ntractor(HIC) H1C Comp or Hlf��R 'strain N HIC Registration Number Expiration Date No. and�S,gg��eeii ��//�� j' &'21/ 0 -c 01" ,O ?7Y "l o Email address Ci /Town State..ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(nG.L.e, 152.§ 25C(6)) Workers Comper:Lation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will -exult 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 BUILDING PERMIT I, as Owner of th: subject property,hereby authorize S to act on my beh:i If,in all matters relative to work authorized by this building permit application. Print Owner's Nan i,(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my r.ime below,I hereby attest under the pains and penalties of perjury that all of the information contained in this.tpplication is true and accurate Atheoef knowledge and understanding. Print Owner's or E athonzed Agent's Name(Electronic Signature Da NOTES: 1. An Owner cho obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registeuxi in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration program or ;,uaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at Information on the Construction Supervisor License can be found at u a 2. When subst ntial work is planned,provide the information below: Total floor area sq. ft.) (including garage,finished basementlattics,decks or porch) Gross living ami (sq.ft.) Habitable room count Number of firep.aces Number of bedrooms Number of bathi:xims Number of half/baths Type of heating:system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Prcj.,ct Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents a Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dla Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Le ibl - Name(Business/Orgaiiization/Individual): Cj. Address:_ ST City/State/Zip: 'GFc)M / ' 005�?Phone O2oZ Are you a player?Check the appropriate box: 1. a employer with 4• ❑ I am a genera!contr]ffie nd I [.YE], Type of project(required): employees (full and/or part-time).* have hired the sub-ctors • ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attache , Remodeling ship and have no employees These sub-contracto , Q Demolition working for me in any capacity. employees and have rs' [No workers'comp.insurance comp.insurance) • ❑ uilding addition required.) 5. Q We are a corporations 10.Q Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercisr 11.❑Plumbingrepairs oradditions myself[No workers'comp. right 152 f exemption pe 12 o repairs insurance required.] t §1(4),and weoemployees. [No work13.0 Other comp.insurance required.] tAny applicant.that checks box#1 must also fill out the section below showing their workers'compensatioa policy information. Homeowners who submit this affidavit indicating they are doing aU work end thou hire outside contractors most submit a new.afdavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer Burt is providing workers'compensation insurance for my employees. Below is the policy and jab site hifonnation. Insurance Company,Name: )eL 45 9jG Policy#or Self-ins.Lic.#: 6r�O Expiration Date: Jryl/S Job Site Address:. /l�i;v� City/State/Zip 5/1/40n t'/Fyn oi1�o Attach-a copy-of-the-wor-lter-s'—compensation-p icy-declaration page-(showing the-policy-numberond-expiration-date). Failure to secure coverage as required under Section 25A of MOL.c. 152 can lead to the imposition of criminal penalties of a fine up to$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 War a copy of this statement may be forwarded to the Office of _ Investieations of the DIA for insurance coverage verification do hereby cer[r�turd r Uie a d penalties gfper' S ry that the information provided above i-'•ue a d correc Si afore: � Date: f Phone#: 0 fda Ilse only. Do'lot write in' its area, to be completed by ci ty or town official 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#: t i A�� CERTIFICATE OF LIABILITY INSURANCE *Al2�,; TI39 CERi1RCATE)S 1=60 AS A MATTER OF LWJIMATION ONLY AND CONFERS NOAFFORD gIDHT9 UPON'THH CERTIFICATE HOLDER THM CIITIIl'"Et 0058 NOT AFFIRMAMVMY 04 NiAATNELY AMEN% 6yyENO OR AURA H9 COVERApE ' T716 ISSUWO INSLIPO(Sh AUTHOn=REPRE'SENTATWE OR PROOUC634 AND THE OF INSURANCE DOES CtERNRCATH HOLOE CONSTITUTE A P NTRACT Aar REfYYEEN DIFORTANTI If the OyWkfftf"orb on ACDITICNAL INSURED,thaI)II&Y na)mustha mdmo;L N 3UBROOATION IS WAI,YED, wpJeetmNatermsaMDendhlmsor the poDay,arm paD nmYmgWre en endveemeDR Aelatemm�t oa thla ea+tifimeEo6a not ra,dar dghmm91sDeniRcafe hRMeP SI EeU atsuch ends Mk PROPLtM CORwCr MARKErWAALLS �630CINSAGCy160 "® e fil PNONe FAS NEWTON,MA 02459 215URePofiAFFDRoeG COVaRgG6 NA141 w[LRAR A:AC6 AMPF�dN HAUPANOE COM,ti;M NSIIRW ' VALDEZ WILSON DSA MASTER ROOF INeDpERBt A UNIENVIOUS-MA wwReRe: PO BOX Ib WILFORD,NA 01767 ' • INBuRER E, 2MRPA F, UMBER: NEWS THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE'LWED eE•1.OW HAVE SEEN ISSUED TO TI1C INSURED NAMED ABOVE OTq THOTHrAE POLICY PERIOD INDICATED.rrHRIM 1*0 WH4ON T NO ANY REOUIREMENT,TERM OR COMMON OF ANY ODHIRACT OR AFFORDED DOOL1MIn?TT WTIH Rt:SpEOT TO WHIOH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INb'11RANCE AFFORDED BY THE POMES OSSOPoB60 AERSM 14 SUBJECT TO ALL THE TERMS, aCCLUS10NS AND CONDITIONS OF SUCH POUOIES.LIMITS SHOWN MAY HAVH•BEE1t REDUCED Ey PAJO CLAIM& IMeR d ormmwcl Ed PIXJDYxVNp7Fe 1'O<myar P wor �� Lt1fUM d0MMWWL4k06NMgLI'5Wr eACH00FORRP+= f ��woe El WWII am N o of f P &A wmmr uwmm v sleet DEMMAQOREWE , POUDY P,m• I.= PROOUD ATPAGO f MO WALNY f ANYAUm i 2 4tLOMIED 6ONmomPo eODAYVLIUAY(Pp pyf f RAW DONaw11eP 90mLYWtP1Y(Pm„rilag NW®AU10s AV,pf f ' UYea6LL,ALfip ppDUA � f EMM UA9 DLAeA4NA0L WCx OdS,RRBIpE f one RMEN v - f ANOB'ROYmISWWUIY ♦,� x W STATiL ply AM'PROIPoOrCMPARTNsryX�VCU yP""' 'R19YLA1 y oFAOe11MEMlVa,EatWm?D7 y I!A 6L EVA,ACOIoeR/ PIDD,000J eYP w."M" . 574 03-15-2014 0}iS2M5 o66T56-FATAxeDYE6 Sl('OFOW- The wrkwm,rylenfatlonpolay doff nOtpmNde mV6 EF,WILWX THE INSUREDS MA WORKERS OOMPENSA1'ION PDXYAND ITS LIMITED OTHER STATES EI'DORSFAtEM AUf}ipRRES THE PAYMENT OF BENEFITS FOR CLAIMS MADE.BY tNE PISURF178 MA EWLOY$91N STATE$OTHERTHAN MA. NO AUTHORI)AYION W LIVEN TO PAY CLAIMS FOR BENErrM IN STATES ORIER THAN MA IFTHE INSURED HIRES,OR HAS PROVIDE FOR ANY STATE OTHER MA !•5RE0 EMPLOYEES OUTSIDE OF MA. PHIS POLICY O0E9 NOT COVEFTACiB 7IWN 3 9 . . .. LOW $OONPAMES INo -. .. ... 4. ' ATTN:IS O URANCE SHOULA ANY*OF*7745 ABOVE 0E9CAIBED POLIpEg.H POMXIIII CANCELLED EEFORE THE EXPOiAT)ON DATE THEREOp ' I1 W LIMEBORO,NC 28B99 NOTICE MALL HE Q&IVERED IN ACCORDANCE WRH TH . . .. . ' P OYISIONB . AUrINI�RO�RDIBTTAi1Y8 I ADORD 25(2WQ/05) Jam 4 WPTA a-._,d'n The AOORD om ro old logo are J2gtstaed ImTHm o1 ACOR r r Massachusetts -Department of Public Safety Board of Building Regulations and Standards- Construction Supen isur License: CS102403 rA WU SON R VALD= 'x !SS MAIN STREET MI LFORD MA 01757 J�-�ll� . 111e E::pirati:,n Commissloner 11120/20.14 ._- Office of Caosomer.%fraln&se'sieess Rn:siadnr .HOME IMPROVEMENT CONTRACTOR ` r Registration: 1505'7 Type Expiration: 4r11� DBA MASTERROOF WILSON VALDEZ 151 MAIN ST • ..Y:MA..�.._i o-h• MILFORD.MA 01757 l oJcrsecri tan •• CITY OF &L .r'M, MASSACHUSETTS p , DU=ING DEPART" tcvT 120 WASHINGTON STREET, 3'F C)ok TEL (978) 745-9595 F.1.Y(978) 740-9846 KI\IBER.L.EY DRISCOLL MAYOR, THoauu ST.PtERRH DIRECTOR OF PUBLIC PROPERTY/9u=l:9G C0\1MISSIONFM Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricianq/Plumhera A + +ticant Inforrnrtinn pleave Print Legible! ,Milne tl3usincssUgm+iralinn;individuaq:,) Q ; � _,. •"_„ Addross: City/State/Zip; O/9 D to phone 11: - 74 ?-9- Are yyu an employer"Check the appropriate box: Type of project(required): I. 1 am a employer with�_ 4• ❑ I am a gcncmi contractor and 1 g, Q New construction - entpinyccz(full and/or part,[inne).• have hired the sub-centractor3 2.(] I ana n sole proprietor or partner- listed on tht:attached sheet.t T. ©Rcmadeling ship and have no employees These sub-contmatora have 8. © Demolition working lbr me ire any capacity. workers'comp,insurance. 9• © pudding addition [No workers'entnp. insurance S. El We are a corporation and its regttitcd.) aflieels have exercised their 1U•❑ Electrical ropairs or additions 1© I am a homeowner doing all woric right of exemption per MOL I L❑ Plumbing rupuirs or additions myself.[,a workers' sump. C. 152,§1(4),and we have no 12.❑ Roor repairs insurance required.) 1 umpkayeas.(No workers' cutup.insurance required.) 13.0 Other •nny applleanl That dteeke Vas 01 moat also all out the ancaun below showing their wmken•compensation policy inllmeation. 'I b.mcmcrtinv wh.+submit thin omehwit indicating They are doing all work and then hira ouhidecontmchIM mtgl aubmi+anew afr?davit indicating such. :('ontmcurn thol check this bus mtat anaehvl an ndditiorwl xhrut showing the mmre of tho sub•contncton end their workcn'comp,policy inrurenmian. /unr urt enrplpyrr!lrrrf Js pruvJdin�tvcrrGers'c•onrperrtn!!un hrttrrnncefor my empluyser. L)e/ulv/s rbe policy turd fah airs lnjarvnnriurc. Insurnncc Company Policy 4 or Sclf4ns. Liu.N:-& /(2-z �/t3 9—YeJ�. Expiration Datc::i7 ' Job SiteAddross:-r— [ frf.P y � city/state/zip;,_J5 .\mach a copy of Itoo workers'to eal I;atlo la pulley declaratlon page(showing the policy number and expl ratio a dato). Failure to secure coverage;is required under Suction 2SA of MOL e. 152 can lead to the unposition 0fcrimin4l penalties of line up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the farm ofa STOP WORE<ORDER and a fino of up to$230.00 a day against the violator. lie advised that a uopy of this slatcmunt may be forwardud to the Oflice of im atigwinns of the DIA ror insurance covonge vcriftcation. I da hereby rerrlfy order Nee pahts and pens rlev of perjury that the infnrruudon prov ui�rrute nand cur rrt S1mLLL41LSy�F�'��� Po 9 l [I, ;vial ue•e only. Du 12at write in that urru, to be coorldeted by city a to ova afjuuL or Town: I'arml0 jet.rise 4 ing Authority(circle Una): oard of Ilcalit) 2.Building I)cparI ocHt .1.Clyll'uwa Clerk 4. F;Irctrkai Inspecrur 5- Plumbing inspectorther tuct 1'c r.ann; Phnnc ek CITY of S,1.L.ENf, jA15S,lCHUSETT5 -;I/ E1t:ti.oL�tG DEP:1R7'tIEYT 110 W.►ij4=,TON STREET, Y*FLOOR "~•. T E (978) 7454595 FAX(978) 7-0-984S ISlJBF.ltLEY PItiSCOLl. Am ! T�{OtiLiS ST.PtERrit3 OIR.ECTOR OF PI;BLIC PROPFRTY/BL'fLDLYC CO\LIUSSfO.FIR 'Construction Deb ris #]ispasal rat'#idavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section l t 1.5 Debris, rued the provisions of t P titG.1r c 40,3 34; Building Permit # ��� is issued with the condition that the debris resulting from this work shall be dispo:>cd ut in a properly licensed waste disposal facility as defined by MGL c t l 1, S I SOA. 4, the debris will be transported by; - � (name of hnulur) The debris will be disposed of in ; (narre of f;tcd'fty) (:.I taeilito T w ' Yl,l�ltq Nl(C Ot�C,lryl(,ltlP11' r -~` Ln ' ip �, i i,Q;„ d � �a N� i.s