91 ORNE ST - BUILDING INSPECTION �o3 '�i CYL/
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SAMar Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D Applied:
Building Official(Print Name) _ - Signaturee Date_
SECTION 1: SITE INFO N
1.1 Property Address: 1.2 Assessors p&rarcel Numbers
L l a 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(11)
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:
Zone: Outside Flood Zone?
Public❑ Private❑ — Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP
2.1 Owner'of Record:
Rb6-e. r Ljt, UUZ1ypn/' 17S �S J C
Name(Print) r City,State,ZI
�� Se e q?y 7Vg-Q pS- h 1AL.,5 �
No.'and S Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) ;
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : f jay Q �p�f%�J �Q z
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $
❑Standard City/Town Application Fee
❑Total Project Cosh(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: L Cash Amount
6. Total Project Cost: $ ❑Paid in Full "❑vOutstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
NNama oCSL Holder
List CSL Type(see below) y
No.and Street Type Description '
�Gt U Unrestricted(Buildings u to 35,000 cu.ft.
�Y�/��/(� R Restricted 1&2 FamilyDwelling
City/Town,S e,ZIP' M Masonry
RC Roofing Covering
� WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /�7j7 � 1°
✓/��✓� HIC Registration Number xpuation ate
I�[C Name or HIC Registrant Name
No.a Street Email address
,/ k, °/sue
City/Town,Sta 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 ........>4 No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIEES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize�� J�
to
act on my�behal ,in all matters relative to work authorizedby this building permit application./
4 - �1 v 4 a\O�QJr p( e �/ 7
Print Owner's Npe(Electr is Signature) —T Date
". SECTION 7b: OWNERt_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 be t of my knowledge and understanding.
Print Owner's or Authorized Agent's NKn&(LTecU46ffic 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigadons
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers'Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Husiness/Organization/Individual) �� ti//�iCi'/
Address: 4;�b
City/State/Zip: f Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
L.0 I am a employer with 24. ❑ I am a general contractor and I
6. ❑New construction _
employees(full and/or part-time).* have hived the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7..{ Rertrodeling
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. [1 We are a corporation and its
required,] officers have exercised then 10.❑Electrical repairs or additions
3.111 am a homeowner doing all work right of exemption per MGL I LEI 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' 13.❑Other
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compemation policy information.
t Horraw" rs who submit this affidavit indicating they are doing all work and than hie outside contractors most submit a new affidavit indicating suck.
Contractors that check this box most attached an additional sheet showing the name ofthe subconbscmrs and their workers'comp.policy information.
/am an employer that is providing workers'compemadon insurance for my employees. Below is the policy and job site
information. _ �s �
Insurance Company Name: w p !'P &_1 C y'�'
Policy#in Self Lic:#: ,�[,�%7��/ �//�Z ..Expiration Date:
Job Site Address:_,%4&�z -_I% City/State/Zip: e
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$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 that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for.insurance coverage verification.
/do hereby cerf�ify/u�ithe pains ofperjurythat the information provided above is true and correct
Sipnamre t:%//� Date:
i
Phone#:
Offrcial use only. Do not write in this area,to be completed by city or town.officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4:.Electrical Inspector.5.Plumbing Inspector
6.Other
Contact Person: Phone#: