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6 PATTON RD - BUILDING INSPECTION (2) v0 � 7 , 13 r The Commonwealth of Massachusetts Board of Building Regulations and Standards CffY OF (Massachusetts State Building Code, 730 CNIR SALEM Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate mo i a One-or Vivo-Family Dwellin Chis Sectio'For Offi ' siohly. Building Permit umber, tti,Appli rd' Building 0(ficial(Print Name) Date SECTION 1:SITE'INFOMIATIOIY 1.1 Prope5ty Address 0 1,1 Assessors Map&Parcel Numbers ho 4 ffo�. o� L la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Ares(sq it) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided ' 1.6 Water Supply: (N.O.L e.40,§34) 1.1 Flood Zone Informations 1.3 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es❑ SEGTIONI PliOPERTId'OWjVERSIiIP! 2.1 0 nert of Roc : � t4K c/ e (l e y, 2 'AL I �4dr ama(Print) City,State,ZIP No.and Street Telep one Email Address SECTION 3: DESCRIPTION OFPROPOSED.WORK°(check llthatapply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg, ❑ Number of Units_ Other ❑ Spectly: Brief Description o Proposed Works: e u SECTION I: ESTMLAIED CONSTRUCTION COSTS Rem Estimated Costs: OfRclal Use Only.. Lahor and bfateriais Y' . I. Building g O® I. Building Permit Fee:S fndi 1te haw fen is determined: r. filectrieal y ❑Standard.City/fownApplicationFae Q'fotat Project Cosh(Item 6)s multiplier x 1. PlumhI . i ). (jther Faes: .S I ,Mcchanic.tl (IIVAQ y List:_ i. �lach.mir.tl (Pisa (blal All lets: S l'hark No.i f] I' Check r\muunt: Il,fal I )njcct ( ',nit I $ 51 . —_('•c;h :\aware __-- I .ri,l n I'n11ll _ , _.❑t)!it;tauJinq Ilal.ute� Ihi:: - _ _ src'rION it c(LVS'rRUcrION SEI(VICES 3.1 Constnrction Suverviiur License(CSI,) � �Qd � \ a License Number ipir wn Uate Na�Ilo List CSL type(ice below) V cent _1< OL� Typo Description ' No. and Street O Unrextrietud Duildin s u to 33,000 cu, tt. /C7UCt�S'1'j/e It Ruxtricted I:42 171111111Y Dwallin City/town,State, ZIP N Rootnr i RCRuotin Covcrin \vS window and Sidin SF Solid Fuel Bunting Appliances dg s'd cPz/y / / ASYra1� o t��,o rcc�l' t Insulation l'ele hung f G(eY Em II uddrcss v �1 e U Damalitiun 5.2 Registered Home Improvenr Co trnctor(IIIC) y��� ,,L IIIC Reglstrtton Number E.rpirl)t on Date III C'um any Name or IIIC Itcgixtr�l�Na a /, do fQC�C irr r�tf ✓je L.• �1�C T Emai address N a d Street 6 e Ci /Town State ZIP Tale hone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(h1.G.L. c. 152. ! 25C(6)) Workers Compensation Insurance affdavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building'pe Signed Affidavit Attached4 Yes .......... ❑ No...:....... SECTIOi 17a:OWNER AUTHORIZATION TO OE COhIPLETED W HEN OWNER'S AGENT OR CONTIL\CTOR APPLIES FOR BUILDING PER11141 I, as Owner of the subject property,hereby authorize to act on Iny behalf, in all matters relative to work authorized by this building permit application. Data Print Uwnar's Nmne(Electronic Signature) NERI OR AUTHORIZED AGENT DECLARATION SECTION — OW By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information containe 41 this application 1 true and a., ura to the best of my knowledge and understanding. 7 � Data I'f It 11W llef'i Jf r\utlturin:d:\gent'i N.une(Electronic Signature) NOTES: i. :\n Owner who obtains a building permit to do hisrher own work,or an owner who hires an unregistered contractor (nut registared in the Home I ill pro ve went Cuntractor(HIC) Program),will IL)j hava access to the arbitration progr:un or guaranty tiutd under M.G.L. c. 1 12A. Other important information on the HIC Program can be found at WW ww nru+.-sw%oud hifurmation on the construction Supervisor License can be found at www.nraz..�t �1 F2. %V hen iub.it:utti;d Work is planned,provi.le the information belu'f,it finished baiunrnVattics dccl's ur porch) lloor.irea(i,l, 11.) (includinyy: g ,livingm-ea(i11. 11.1 Nomberolbedro,nni-------- Nulnher,�fh.11ebalhier,rfb.uhnann.; .._ .. -------X t1IIlbir tit ,lacSi/ rorcl1Ci 1•e i,t jt '. I',rill'ny.•,:t � pur.. I� ,�1 , ::' ul.rvi+a �nh,nnit:Jl;,rf,.r.11l'nq :�tl1,,t,. r V� JaiLyy'if, 1Al JJi,l..i7US 1 lS t� 1 QL'I=LYG 0EP.lanLE,-4r :bK,yr�.,+ 1_'O W..uMGTOV ST(tE8'r 3'D Roo:t A, T�17[. (973) 7t5.9595 <n(0F7.1 y 0RISCOLL FL't(973) 7.14.934.S ty0a 1110N&U Sr.PIEdIts 011ECTOR OF pcouc PRopeQTy/SvanLVC CoSottsslovE Q Construction Debris Disposai AffIduvit (required tot aU dcmalitian w1d ranuvatiatt work) (n accardanca with the sixdt editiun of the State Building Coda, 730 CMR section 111.5 Debris, 'uld the provisions of A,(CL e 40, S J4; ©wilding Pull b 9 this wur!<shall is issued with the condition that the debts resultin e dispuscd at'in a properly licensed waste disposal g Prom 111, 3 1 SOA. faatlity as da$ned by ,Y(CL a The debris will be transported by; (junta ut'haulw) Che Jvbris will ba dispased Orin : d� (manic tiretrJC ty) L% i•pumranf L2� .,termit.ipplic.uu � cA CITY OE SM-EIM, iltLXSSACHUSETTS BELL .NG DEPift'M NT 120%Y(/.iSHLNGTON STREET, 3"FLOOR. TEL (978)745-9595 F.tx(978) 740-9846 KI%Br Ri F.Y D1tISCOLL THOMASST.PIERRB MAYOR DIRECTOR OF PUBLIC PROPERTY/Bua.DL`!G COMMISSIONER Workers' Compensation insurance Affidavit: Builders/ContractorslElectricians/Plumbers Applicant Information Please Print Legibly Name(Busiix &organizatiaruindividual): Address: ��/i�ry LL/��s L� of &4-e City/State/Zip:_J ucea4t ¢S Q4y ['honeH: Are you an employer?Check the appropriate box: 'type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contragtot and 6. []Now construction nployees(full and/or part-tima).e have hired the subcontractors 7• ❑Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These subcontractors have S. ❑Demolition working for me in any capacity. workers'comp.instuance q, Building addition (No workers'comp.insurance 5.'❑ We are a corporation and its. rcyuirert) officerd have exercised their 10.❑Electrical repairs or additions 3.111 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions myself.(No workers'comp. c. 152,g 1(4j and.wit have no 12.0 aof repel / insurance required.)t employees.[No worker': 13.(jd Other d G comp:insurance required.]. -Any applicant that checks boa it l mutt 31W fill aM the section below showing their workan'compenwlm policy inf t modom t Ihvnvownevs who submit this affidavit indicing they are doing all work and then hits outside cantmetors mug submit a new of TiAvil indicting such, :Comrwton that chctit this box must attached an additional Awl showing the name of the subavninctore and their wodtart'wants.policy infem,,um. lain on employer chat!:pruviding workers'compensadon ttlsurancejor my empluyeex Below is fire policy and fob site injurfnmlam Insurance Company Name: Policy N or Self-its. Lie.N: Expiration Date: i Job Site Address: City/State/Zip. mtacb 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 ueMGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S230.00 a day against the violator. 13e advised that a copy of this statement may bo forwardod to the OI•l ee of Investigalimu of the D(A far insurance coverage verification. I da hereby c erdj if der flit al un en allies u Mary ul the infurmatlan provided abuv is tr a and correca _I: 7 �� t Dar • . Official use unly. Do not write in fifty urea,to be completed by city or town aff slut City or"rotvn: Permit/l.lccnse* _ Issuing Aulhorny(circle one): 1. Board of lieallh 2. Building Department 3.Cilylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: .__ PhoneN: (