23 PARK ST - BUILDING INSPECTION y
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
1YMassachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a owomwkea
One-or Two-Fumdv Dumlling
This Section For Oftcial Use Only
Budding Permit Nu r: Date Applied: ,�i, e
Signature: q 111V 2
Budding Coff"Isfionif/lInspk6w of Buildings Date
SECTION 1:SITE INFORMATION
2 3o®,r?cd S—F�a 1.2 Assessors Map ec Parcel Numbers
1.Is Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 nl(tg 1� nformatlon.
'/Y 1.4 Property Dimensions:
zoning District Proposed Use Lot Area(sq B) Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rest Yard
Required Provided Required Provided Required Provided
t.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private O lone: _ Outride Flood Zone? Municipal d�On site disposal system O
Public Check if sO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofl% -T Record: 21 3 �GtNlf S� JS�� �rf2
M�ttrter'c��ia � S
Name(Print) Address for Service:
Signature Te ephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) Addition O
Demolition O Accessory Bldg.O Number of Units 2 I Other O Specify:
Brief Description of Proposed Works: S O Sr 2
IJY �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Budding f O U(7r b O 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Elecincal f O Total Project Costs(Item 6)x multiplier x
J Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) f List:
S Mechanical (Fire f Total All Fees: f _
Su ression � —
Check No. _Check Amount: Cash Amount:
h Total Project Cost: f Q O . () (� O Paid in Full ❑Outstanding Balance Due:
G 8��`�'• w�►. r`Pf'e)
1
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supers isor(CSL) 6%4(
(eNumbr Espiration Dute
/ ,LL T1a 7 Gg/rAAkkc 'eM_ (' / YDr 1avY Alow1
s.s.CionSoc/<-e. t o .Yy- Descn un
sf Restricted 1 u to ily D Cu. gFf
Restricted IR2 Famd Dwdlmre Mason Only
U103)�i09- d07D RC RcsidennalRon m Cover
Telephone w'S Reside ofi
ntial Window and Siding
SF Residential Solid Fuel Burring Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52.f 2SC(6))
Workers Compensation Insurance affidavit must be completed and submined with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Afrdavit Attached? Yes.......... O 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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
/�.
Si natwe of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
I .beha f
Print Name
Signature of Owner or Authorized Agent Date
itSigned under thepairs;and penalties ofperjury)
NOTES:
I. 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 I HIC)Program),will g&have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 1 I0.RS, respectively.
2. When substantial work is planned,provide the information below-
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. FL) Habitable room count
Number of fireplaces Number of bedrooms
Number of balhrooms Number of half.baths
Type ofhoting system Number of decks/porches
Typeof cooling system Enclowd Open
1 "Total Project Square Footage" may he .ub,muied for-'Total Project Cost"
CITY OF S.UX.`I, ,N SSACHUSETTS
BL'BDLNG DEPARMENT
120 WAsmv4GTON STREET. Ye,FLOOR
TEL (978) 745.9595
FAX(978) 740.984
KI.,BEjtLEY DRISCOLL THon%sST.PlFm
41AYOR
DIRECTOR OF PLBLIC PROPERTY/III.: DL%JG CONLNBSSIONER
Workers Compensation Insurance Alildavit: Builders/ContractorslElectriclanslPlumbers
.%Dtdlcant Information Please Print Legibly
NaineIdusinvorg4nizationlnLLvtdual): ffl_' •AanR oeco / y
Address: l�- Fi.� 4 )r w/!e r ey-9
City/Stateizip: C"'.1 Y d ✓VI/ 033 Cey Phone a: (6 03) 2/4—Z i 9 0Z
Are you as employer?Chuck the appropriate boss: Type of project(required)'
1.❑ I am a employer with 4. Q I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).• have hired the sub-contractors
10 1 am a sole proprietor ar partner- listed an the attached sheet : ?. Q Remolding
,hip and have nu employees Thews sub-contractors have S. Q Demolition
working for me in any capacity. workers'comp.insunace. 9. Q Building addition
[No workers'comp. insurance 5. Q We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised then
3.Q 1 am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
myself.(No workers'comp. c. 152.#1(4),and we have no 12.Q Roof repairs
insurance required.)t employees.two workers' 13.Q Other
comp. insurance required.]
-Any appllcaal that chocks hot Of MUN Alen rsa Ua use M1100 hot"rhoeteg their workers'eutrtI walon policy infunswaim
t I hwwuwsers who suhnil this atlldwil indicating they are doing all work attd than hire outside casunw es Mou a,ha it s raw anldavit indicri g audL
T.MIIY'b1e(hot IAKk this boa Mao anwhod in 3"liorid owes showing the noose or the aAKean KSM NW their wader,'ramp,policy isrorM,aoe.
/am an employer that is provid/nir workers'cotapenradon/nsuronea for My saep/oyees. Below ls tha paltry andM ilia
information,
Insurance Company Name: G&P?E4 r-j G r ajiie Tn,P �r�✓j`L ,p/b�Q
Policy M or Self-ins. Lie.N: / Expiration Date:
Job Site Address: 2 3 /n� H' J4 f�r r a City/StatdZip: Co ran" ✓4,11 0 J3 O�
,l ttach a copy of the workers'compeasatloa policy detlorallon page(showing the policy number and expiration dab)v
Failure to wcure coverage as required under Section 25A of MOL e. 152 can lead to the imposition of criminal penalties of■
fine up to S 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 5230.00 a day against the violator. Ile adviscd that a copy of this statement may be forwarded to the Office of
Inve.tigariuru ul the DIA for insurance coverage vinisication. -
/Jo hereby cr y under the pains and pen"/des al perjury that the in/armadoa provided above is true,and correct
ore: �!?K' Date! 12 V/
PFone A:
O/liciol oat wJy. Do nor write in this area,to be,urnpleted by airy or town op9rielt
I
City or ruwn: _ Permit/I.1cense
Issuing Authurily (circle )ne):
I. Iluard u/Ilealth 2. Ruilding 0eputment 3. Cityfrown Clerk a. Electrical 6npcctor S. Plumbing Inspector
6. ()iher -
1-„nuct Person: Phones:
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F'I ALE cr'c S'c '� Ste-, Iry ra rc,4 i L .
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�C�J� -y 120 (ice �r�-ram