9 OAK - BUILDING INSPECTION v t
f ', --- I'hc C'ununumvcahh uF fvlassorhusctts -
i1 y; L\ I:.\
, I
Hoard uf'Huilding Regulations and Standards S N
M assachuscits St; is Building Cude, 780 CM1IR
Building Permit \ppiication 'ro Construct. Repair. Renovate Or Demolish a
One-or ruvi-Faunirr Duelling
Phis Section Fur O ' cial Use Only
Building Permit Number: Date Applic •
Iluilding 0117vial(Print Nmnc) Sigar re Date
SECTION I:SITE INFORNIATI N
1.1 Tperty dress: 1.2 assessors Nlep& Parcel Numbers —
I.la Is this an acce ted street? es no Alap Number Purcul Number
1.3 Zoning Information: 1.4 Property Dimensions:
Coning District Proposed lire Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required I'ruvided
1.6 Water Supply:(M.G.1.c.Jo, §54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposals)stem ❑
Checkif yesO
SECTION 2. PROPERTV OWNERSHIP'
2.1 wne t of Recol
r
.���
Nmne(Print City.State,ZIP
No.and Street telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building O Owner-Occupied ❑ 1 Repairs(s) ❑ Alterallon(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ I Other ❑ Spccily:
Brief Description of Proposal Work,: if-dsAG
S C4 . n /-Q d
o
JI
SECTION J: ESTIJIATED CONSTRUCTION COSTS
liens Estimated Costs: Official Use Only
(Labor and Materials)
I, Building S I. Building Permit Fee: S Indicate how tee is determined:
:
O Standard City!Tusvn Application Fee
2. ISecirical S
❑Total Projat Cush I Item 6).x multiplier
1 111unihing I S 2. Other Fees: S x
J. \Icdi.miaal ill\ \('! i List:.—
j \Iechauicatl "1": S ---- - - -- --- -- -- . ._ . ._
vc>siun
Check Va. ('Neck:\nunuu: ('ash \unuwl:
o I'utal Project Cost: i Q�
( ❑ Paid in Full 0 Outstanding 11almce Due:
r ,
SE('I'ION .f: CONtil'RUCTION .SERVICFS
5.1 ('unstruclimt Supervisor Liccnir(C'SL) `0O� ?// ;_
I icensc \'unlher I y,irauan Ilene
,Valhie ol'l'SI. I Iuldef
I is[01, 11pe Isee helussl.__.__.
'1'lpe Description
Nu. Slrcel
/� it l4vcslricteJ I IhulJin i a to it,IAlll nl. IIJ
7.� I(e.tricled IS2 Famil D,scllin
'ihifalul,Slane,%II' .\I \loon
Rlwlin Co%crin
... S O'iodow.md Sidin
�• SF Solid Fuel Ilurning Appliances
37, �QFjS _ 1 Insulation
'I'elc bona Ivnail aJJreis D Demolition
5.2 d flume Imp rut emenI Cuntnutor(HIC) /.Co a /7
12 0a-I-% --I IIIC'1(egistrltiun Number lispi lion I ale
I I tympany tllf! nr Imo('14egislr Nwnv
No. :—Inuce ( /��t�70�'� Elnull address
6tygown. State ZIP Tele lane
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.c. I52.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atlidavit will result in the denial of the Issuance of the building permit.
Signed Affldavit Attached? Yes ........�-v No...........O
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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print URnef a Nallle(ENctrunic signature) Dute
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
coat�I d in this ap ication is true d ccurate to the best of my knowledge and understanding.
;( lit r,7 /-?,� /a
Prim ssncr'say:\�a�ori�ed,\gcnt'sNamelFkctrunicSignalara) Date
NOTES:
I. .\n Owner who obtains a building permit to do his her own ssork,or an owner who hires an unregistered euntractur
(not registered in the Hume Improvement Contractor(HICI Program). will nu have access to the arbitration
program or guaranty fund under..\I.G.L. c. 142.A. Other inlpunant inlurntation on the HIC Program can be Ibuod at
,sls,s n,.n. -,01 ,v I Information on the Construction Supervisor License can be found at „Il,s Ip,
' \\'hen substantial Iwrk is planned, pro\ide the infunnalion below:
row floor area(act. 11.) - t including garage, finished basement attics, decks or porclu
GrosiIi%ingarealsy. 11.t _--._ .._ -_ Ilobitable room count
\umhcr of bedrooms . .
\umberolhathrooms . . \wnherof'hall'halhs I
I\Ile of lll'atlllg i1 Aeln \11111hcr of decki, porches pc dc,vling :�aei❑ I'nclo,ed 11l,en
t "IoI,dPnljecl SIIIGIfC 1UJLIge"tltay 1,e.UhiI11111Cd IiV"filial l'fujeel
CITY OF S,U-&Nis A%ss.1CH(:SETTS
dL'tLDNG OEP.1RT.%tE%ir
120 W-UHNGTON SrUST, )'O F20O)t
rEL t979) 143.959!
K1313FRF Y ORL OLL F.Vt(978) 7149t&w
MAYOR 1}iousui ST.Ptztttui
IJIAECTOR OP Pt.BL1G PROPlRTy/g�'QDNC CO►L♦II51tOV EIl
Construction Debris Disposal Affidavit
(required for all demolition and rcnovation work)
In accordance with the sixth edition of the State Building Code, 730 C,btR section I 11.J
Debris, and the provisions of MCL c 40, 9 34;
Building Permit At this work shall be disposed of in a p is issued with the condition that the debris resulting m
1 11. S I JOA. ro froperly licemed waits disposal facility as doBncd by NICE c
The debris will be transported by:
� ,
in+ma auler)
The debris will be disposed of in :
(name ar/acduy
(,dOreu .silty)
�MNtO u permit r ic�nr
lA fa
CITY OF S:u_Eml NWSACHl;SE"ITS
i BUILDING DEPART\LE.NT
120
\,V.%SHLNGTON STREET, 3'a FLOOR
TEL 973 735-9595
F.kx(973) 7.$0-9844
j.N113EI E.Y 0RISCOLL THOSLvsST.PIF—RRR
LAY01
DIRECTOR CF PCOLIC PROPERTY/BR:RDINr CO%L%IISSIONER
Workers' Compensation insurance A17Td•avit: [3uilders/Contrnctur.v/ElectrlcianslPlumbers
li t illeant Informatinis Mast Print Lefzihl
N;iinc iltueiiw,.o Crgamrniiamin I iduall:
Address:
CityiStatc/Zip: Phune N:979 7d a
Are ynu an employer?Check the appropriate bolt 'Type of project(required):
1. I am a employer with 4. 0 I am a general contractor and 1 6. ❑Now construction
1nplayces(Nil and/or part-time).* have hired the sub-contractors
1.❑ I am a sole proprietor or partner. listed on the attached.rhee11. t ?• ❑ Remodeling
ship and have no employees These subcontractors have I. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. 0 Ouildiug addition
(No wurkcrs*.comp. insurance 3. 0 We area corporation and its
rcyuircJ.(
oMcers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homcuwnar doing all work right of exemption per MGL 11.0 Plumbing repairs or udditions
myself.(No workers'Gump. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees.[No workers'
comp. insurancemquircJ.) l3.❑ Other
-.�my apphc:un iI W ahcvaa bon al must atao all ,ul Iha weliaa bulaw ahawins Choir"lien'compenadun puliry inaomadon.
'I hvnauwmcn who,Omit this attlabtvii Indicasins They an doins ail wore and then Mn Will&caNnetore mint nthmlt a new ailidavit indicuins.oak
!0,mmton that cheat his bus must aaaehad an eddtlfun i ahfi,huwins Iha nwne of the mb.oninaNa and Ihalr worYsrs'mints.paltry Infurmalion.
I urn an eulpluyer thaN.prow! Below/s the polcy and job rile
infururutler4 r ,./.. T
In.,umnce.Compuny Name: V J_,y-__
Policy d ur Self-its. Liu. d: Expirution Date:
lob 5ita Address: lG eSaT— Cityistutedzipt (�
.Attach a copy of the workers' compensation policy declaration pigs(showing the policy number and expiration data).
F.61uru to wcure cuveragts us required under.Sucdon 25A ot',MGL e. 152 can lead to the imposition of criminal penalties of a
tine up to i1,500A0 und/ur one-year imprisnnmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a lino
of up to 5230.00 a Jay against Ilia violater. Ile advixcd that a cupy of this etalvincnt may be furwurded to ilia OI'tico of
Live,tigutiuns of the f)L1 I'or inaurinee covaragc wart ticaliun.
1,10 hereby /A��V r\mJ�er sir pain ud peno/r e. ,/ erjury that the infuratutlan provided above is true attd correct
i� •r llur<�� � Ilatu: ��_�
011hial nee only. Oo not write in thh area, m he cmuyleted by city Of town.r livial
Ciry or 1•uwu:
Muio� .\Whuriiy (circlaona): .. ...__ .
I. t1wird 14Itoolih !. MiildInq Depoctinum 1. ('ityi town Clerk J. Electric it lll,pector i, Plnothin.4 Inspector