41 OSGOOD ST - BUILDING INSPECTION 4 �?4 o c�
3q - $2.5 00 1
The Commonwealth of Massachusetts
� CITY OF
Board of Building Regulations and Standards SALENI
I Massachusetts State Building Code, 730 CNIR Revi.ved.Nur 2011
I� Building Permit Application•ro Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Onl
�B�uildmgPermitumber; Date Applied:
building Ot'ticial(Print Name) Signatu ate
SECTION 1:SITE INFORMATION'
I.I Property Address: 1.2 Assessors blip d'c Parcel Numbers
S7-
I.[a Is this an acce ted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Lot 1t Frontage 11
"tuning District � Proposed Use 4 ) g ( )
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:Qvl.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2. PROPERTY OWNERSHIP'
2.1 Owner'of Record:
DrXti�aCO H�lr�ow
�1me(Print) City,State,ZIP
!Z stl�4 ?79 5� 4�9 23 9 " 0
Nu. mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other W Specify: )LCY7,st 2b
Brief Description of Proposed Work': i^/L 0ti
C Ss C
e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing $ 2. Other Fees: S
I.Mechanical (1-IVAC) S List:
5. Mcchanic;d (Fire S fatal All Fees:S
Su rcssion)
Check No. Check Amount: Cash Amount:
C.Total I'rgject Cost: .S mob vo® ❑ Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5A Construction Supervisor License(CSL) C,y �D 196 5-- ll 2 l
4 c� iz i e p t,e A&;— SiL License Number E.e tralio Date
N:une of CSL fluld�r List CSL Type(see below) ✓�
T e Description
Nu.;md Street
1I /1 U Unrestricted(Buildings u to 35,OW cu. It.)
'ffa)!� ^//1/ l� �7 - R Restricted 1&2 Family Dwelling
Vity/fown,Stat ZIP ibl Masonry
RC Rooting Covering
WS Window and Siding
/fl� SF Solid Fuel Burning Appliances
57 Z O '
1 1 Insulation
Te-Jcplllubd Email address D Uemolitiun
5.2 Registered Home Improvement Contractor(IIIC)
E! ®PD ;2. HIC Registration Number E.ep' utiun Date
HIC Coinpany Name or HIC Registrant Name
No.an p d Street rimp 7 llfps --o! e,/ —� Email address
t Cityrrown,State, IPA ! 'rele hone
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 .......... No...........O
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's N:une(Electronic Signature) Date
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.
Print Owner's or aKulhorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or anowner who hires an unregistered contractor
(not registered in the dome Improvement Contractor(HIC) Program),will nrr!have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass. soh:�0=:1 Information on the Construction Supervisor License can be found at www.ina,,..:ov'JL
�. When substantial work is planned,provide the information below:
total tloor area(sq. R.) (including garage,finished basementlaltics,decks or porch)
Gross living area(sq. It.) Habitable room coma
Number of fireplaces Number of bedrooms
Number of bathrooms `lumber of half/baths
rype of heating system Number of ducks/porches
type of cooling system Enclosed Open
1. "I'otal Project Square Footage"may be,nbstituted liir"ruLd Project Cost"
° CITY OF &U-EIM, ANSSACHUSE-M
G
• BUILDING DEPAR"ME-\T
120 W.ksHLNGTON STREET, 3so FLOOR
TEL (978) 745-9595
F.tx(978) 740-9946
KIMIBERLEY DRISCOLL
MAYOR T1iOhfAs ST.PIEME
DIRECTOR OF PUBLIC PROPERTY/BUMDING COSNISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant lnformatinn �Please Print Legibly
NiiiTic(ilusiness,Drganizalit)w[nLfivi(Iual):
I �
Address: 2 �-7 e 'i'5 --:57--
City/State/Zip: D Phoned: P 25 ' 7'K40 '065
Are pla,
an employer?Check the appropriate box: Type of project(required):
I. am a employer with_ et4 _ 4, ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ 1 mm a sole proprietor or partner- listed on the attached sheet.t 7• ❑.Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp. insurance. y, ❑ Building addition
[No workers.comp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their to.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumb' •repairs or additions
myself. [No workers'comp. C. 152, §1(4),and we have no 12, oof repairs
insurance required.) t employees. [No workers' j3.❑ Other
camp. insurance required.]
•Any applicant that chucks box AI most also fill out the section below showina theirworken'cumpensmion policy inlLrmatiun.
'I fomeowm"who suhoit this attldavis indicating they arc doing all work and then hire outside contneton most suhmil anew aft?davit indicting such.
;(loom-tun,thin chvvk this box most anachcd an addiliurrml shMl showing the n:unu of the rubaomncton and their workers'romp,pulicy inrotmafion.
f ant an employer that is pravi ding workers'c'otnpensadon insurance for my employees. Below is die polfcy mad fob site
information.
Insurance Company Name: %2+eC/6£-_Qa'-' �jp (�
Policy U ur self-ins. Lie.o: VC Cf- g UU77 L 3 '-� •'/ / Expiration Date: Q P
Job Site Address: 940DD .SF' City/State/Zip:,
Attach a copy or the workers'compensation policy declaration page(showing the policy number an explratlon date).
Failure to secure coverage as required under section 25A of MGL c. 152 can lead to the imposition ofcrintinal penalties of a
line up to S1,500.00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up m S250.00 a day against the violator. 13e advised that a copy of this statement may b:forwarded to the Office of
I nvest igw ions of the DIA for insurance co vemge verification.
l do hereby eery under the paLts and penalties of perfury that the hnfaraluton provided above is true and correct.
�—
Phone
e /TT
Official use only. Do nor write bt this area,tube eonnpleted by city ur town offfcial
Ciry nr Town: __._. . .__ PcrmitA.lccnsc k
Issuing Aulhurity(circle one):
I. Board of Health 2. Building Department .3.Cilyffuwn Clerk 4. Electrical luspector 5. Plumbing inspector
6.Other
Contact Person: _. _ Phane n:�_
[
CITY OF S'u2m; U-USACHUSETTS
131:=LNG DEP.\R't1lENT
, oy 130 W.SSHLNGTON STREET, Yo FLOOR
TFL (978) 743-9595
KI J BERL EY DR ISCO LL RUX(978) 740-9844
NLAY01t -11-10SLi3 ST.PIERAS
DIRECTOR OF MLIC PR0PE1kTY/8t.'tLDLNr1 CONNI55TONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of N101. c 40, S 54;
Building Permit !t 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 ,%V(CL c
111, S 150A.
The debris will be transported by:
y ,
y p4e4f' D moo
(name of hauler)
'['he debris will be disposed of in
e
yo %ter f S/D �i�.c y .,cIZS
(narne or taality)
address ot•raciti y)
sisnatureorpermit.tpplicant '—
d.uc --