15 ORD ST - BUILDING INSPECTION 7 I'he C'unnnunsccaldt of Massachusetts
Board of Building Regulations and Standards Cl IN OF
r� \ Massachusutts State Building Cude. 780 C NIR NALEM
L•,.•
Building Permit Allplicalion TO Construct, Repair. Renovate Or Demolish a
One-or i"is o-kamdr Dive/(ing
This Section Fur 011icial Use Onl
Building Permit Number: Da"plied: -a
Ilui(Jiny Ulllcial(Nrinl Nmne) Siµnaµo taro / /
SECTION I:SITE INFOR51ATION
7Supply:eny Address: 1.2 Assessors.Hap& Purcell Numbers
o A s7is an acre led street? of no Map Number Parcel Nwulxr
ng Information: I.4 Property Dimensions:
trict Irropowd Use Lnl Area(sy 11) Frontage ill)
In`Setbacks(R)Front Yurd Side Yards Rear Yard Provided Required provided Heyuircd I'roviJeJ
Supply:(M.G.I.c. JU, §SJ) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
❑ Prisu.❑ Zone: _ Outside Flood Lune?
Check If es❑ Municipal❑ On site disposal s)slmn ❑
SECTION2: PROPERTY OWNERSHIP'
Wnerto(R cord.
R� err Ili cti'rmtl try.Slutc.LIP
Czc� s F�6 Q)qStmm relephune In
Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteratlon(s) ❑ Addition O
Demolition ❑ Accessory Bldg. O Number of Units_ Other ily:6fat� �rz rxp g F
Brief Description of Proposed \Vork°: .41ra— c--- F
SECTION J: ESTIMATED CONSTRUCTION COSTS
ltcm Estimated Costs:
IL.thur;md \huerials) 0111ciul Use Only
I. Building S I. Building permit Fee: S Imdicate how tee if determined:
'. Heclrical S ❑Standard City.•Tuan Application Fee
❑Total Project Cush I llens 6)c multiplier s
_. Usher Fees: S
J. \Iccli.ulic.d ill\ W1 i List:
\Icch.mic.J ihrc
o Yulal Isrnjcct Cmvt i OC� ( 11"k \a. _ Checl, Al" nuu, . _. ._. C.ioh \m.nmc
0 P.iiJ in Full 0 Ontsewding BaLwce Due:
SECTIONS: CONSI'RUCHONSERVICFS
S.I Construction Supcn isur License IC SL1 �o j � _ /Q _�o I��
1 icons.Number pynrnlian Dale
N,une of l'51 I Ioldcr .._.__—_ I Is1 CS1. I\pe(Ice -
� Deicri lion
Na .ud Sir
ccl _ ___ 11 IhlrestridaJ IIhulJin s li to l),000 w, IL1
y,i �fy-) O( 5 vim_ _ __ R lu,irwled IRS f.unil Docllin
\felon
Ciq I all n,Sidle,LII'
I H1w1in l'aserin
A w'indolr.old Sidin
- SF SuliJ Fuel lluming:\ppliances
huuiwiun
l'rlc hone
fmail:ddress D Demolition
5.2 Rrglstered flume ImpruvamelU Contractor(HIC) �111 7 -) U o2`5 dO l
ll ,tin Rr ipNT32( �f�t_� 2v�tro^ IIIC' Itc6i>,IrtliunNunther F\piruliunUalu
I IIC'l'omptit) Nonce or I IIC Itegi.,trunt Nana
Entail address
Nu. mid Street U/ 7 B/ /.2 1
L �J
Ci own, State ZIP role hone
SECTION 61 WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.I.e, 152.1 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 AMdavit Attached? yes .......... G3 No...........0
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 Io work authorized by this building permit application.
Date
Prim Usaler'a Nu+ne IElectrunie Signuturv)
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 accurate to the best of my knowledge and understanding.
) tl r•,1�t2 IaAr`�— 6- a4 -a�r�
1'rinl,Usl ncr's ar:\udnnveJ,\gem +Nenw Il,lestrunl�.Slgnauuvl
Dote
VOTES:
I. .\n Ossnrr ssho obtains a building permit to do his.her own swrk,ur an owner who hires an unregistered eonlractur
uwt registered in the Hume hnprovcnlent Contractor(HIC) Program),will nu have access to the arbitration
program or guarutt) fund under M.G.L.c. 142A. Other important information on the HIC Program can be Ihund at
,1111s n1.r.• - 11 . 1 Infonn;oiun on the Construction Supen isor License can be found at Ills 11 t1�.'� �!t •Ih,
\\'hen subsianlial Iwrk is pl:uutcd, pro\iJe the infultincllu n bcio`r ye. finished basement anies,decks or porelu
f,nai tlour area I:+ 11.1 - _---_- g gore
flabit.lhle room cuunl
Gross IN ing area I iy. 0.1 ._. ._. .... . - \anther of bedrooms
\IIntbcroftirvplaces ., .. _ --- \unthcr tit hall halhi
\untherol'hathrswnls _ _
I�III: tit Iieolulg i),Icl❑ \further of dccAi porches
f pe.11'troling . .tem
I'ncla.cd . ,t)Ilen
1 "i otal llroiect cgiore I'1,,,I Qe IIM.% I'c HIhHlitacd 111i, I Jill Proje❑ Cost"
C[-1-Y OF S.U.E.%f, AkSSACHUSE"ITS
' I \f 131:ILDING DEP.\Ant��;r
1201'V.15HLVGTON 1O STREET, ) FLOUR
TEL (978) 745-9595
Fill.-C(918) 7449846
v tBE_,U_EY DRISCOLL
MAYOZ THos6\3ST.PIF—Us
DIRECTOR OF P"LIC PAO PEATY/OCR.DI\G COSLQIISSIONEA
Workers' Compensation Insurance rlillTdavit: 1)uilders/Cuntructorv/Electrlc(an.+/Plumbers
4f)pllcant Inform-Ann Ple se Print L02ihly
V;Ilnctnmiiu,r,Ur�anlralior4lndiviJual): (.1, ���/�M 'F(�l�I�/J,n/-( (Z (-n cY-2 r'Fr1/1
Address: 0-I S 1/22o n< < 7—
city/state/zip: YN I✓ .' M r- Phone
Are yo n crltployer!Check the appropriate boss
type of pmJccf(required):
I. l un a employer with / C/ _ 4, ❑ I am a gena•ral contractor and I
dntployces(Nit and/or pan-time).• have hired the Sub-contractors 6. ❑Now construction
2.❑ I:Tire a sole proprietor or pustnur- lived on the ansched sheet, t 1, ❑Remodeling
.hip and have no umpiuyces These sub-contractors have I. Demolition
working for me in any capacity, workers'camp,insumnee. ,
(No workers'.comp,insurance 5. ❑ We are a corporation and its y' ❑Building addition
nyuired•I officers have daereised their 10•❑Electrical repsin or additions
3.0
. I mn a holtleuwncr doing all work right of excerption per MCI 1 1.0 Plumbing repuin or udditions
myself(No workm'comp. C. 152. 11(4),and we have no 12. oof repairs
insurance required.( f vmployees. (No workers'
sump,insurance reyu(rcd.1 15•(]Other
•buy apPlla:un our 016vila boo A mwa also rill aul the rvtiuo bulvw ahaWina Ihalt wrMn'camprnudun pu9uy innummlon.'I h.n.•uw�-n who.uhmir Ihb olilMvir indlwlne Ihry�n doing all�wrk and Ihar hire ouIli.Ja caNmetwf$1,mnr•wn lhal uhVck this ba owl aluchd rn WJulun d Awt thuwiny the nwno of the rub.cuntnWmlur JI-Mnif a mw allJaril indloline
hd Ihalr arlancamp.PulleyInfwmauoe
fain an tarp/uyrr that Jf pruv/dlnX workers'cumpwsrof/un Guurunce�or my e)np/uyrrs @rluw/s du po icy and fob silo
inlornrudaiii.
In..urmco Company /-1 �n...__
Policy 4 ur Self-ins. Liu. d:. d/ ��tp /ct_ E'llirution Date:_ —/ 3'
tub Sila.\ddress:�1 g2Cl < j— ,S'/-y/•eM CilyiState/Zip:_'Y'ZP A rl) /yIh
.\Iruvb a rnpy of the warksn'comparttatlon policy declaratlon page(showing the pulley number and rsplratlos data).
f;lilura to+acuru cuvaraga as required under.Suellate 2JA of fGL c. 112 an lead to the imposirian of criminal penalties of a
I�(till
Tip ro S 0L(]a I 0 andlur oneilgar impri.mnmcnt,as well as civil penalties in Iha form of a STOP WORK ORDER and a lino
of Iq)to 52i2t10 a Jay )gains) Iha viola:Of. Ile advl.+vd that a copy of"his nlutmnvni may bu furwvrdW to Iha 011icd of
•1)'CNIg✓IIutN oI II)v I)Ir\ I�)r in.iurallce c,)vQr.lgc vcriticrliutt.
!Flu lrrreay rrfri/y undrf r60 paint uuJ pnwlNrr:i/perjury rlrur rhr i ubuvr is true vrd t.•orrrca
/)//ici�!rue Tire/y. /ha,r,+f ivrirr in rlrlr err✓, ra.}r run,plritJ 1y riry rn ru wn nj�lri✓[
City or 1'uwa:
Ltuiny Aullo,rily (eirelu ),)e); .—._. -
L :Juan!ul Ilrunh !. IL)Jding Ucp.lnmcul 1. Cilyi hobs C tvrh I. iifzctrlc.it fl qi)"[, �i
u. I)I her _ .. +f i, 1 Illill binq fuvptihv
l'.M1.1II i':Hole
Chg11C If
,- CITY OF S.11_ Nf9 ►%WS.1Cf-i(,'SETTS
JLLMLNG 0EP.I1t-nLLNr
I'0 ')Y.kJHLNGTON STAEET, Jw FtOOIt
1*RL, k973) 141-9595
1C11®taALfiY DRISCOLL FAX(973) 11Q9&1d
.�UYolt 1}IGMU ST.PMAAA
D IRECr04 OF Pt WC P ROP EATY/ft Mn Ma co.waSSION E I(
Construction Debris Disposal Affidavit
(required for ill demolition and renovation work)
fn accordance with the sixth edition of the State Building Code, 190 C� R section 1 I I.J
Debris, and the provisions of MGL a 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting from
This work shall be disposed of in a properly licensed waste disposal racility as defined by ,XICL e
11 I, 3 1 JBA.
The debris will be transported by:
(n.une urhauler)
T'he debris will be disposed Orin :
�tr�2,ve2
1�2 etc;G t c� LyN,J
Wdrrfs or n,,l„y)
ermif ,pf
:lie