60 PERKINS ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY OF
WOE
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR $ALENI
Revised blar 20//
Building Permit Application To Construct, Repair, Renovate Or Demolish a
one-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date.A 1
Building Otticia (Print N:une). Signat,
SECTION C:SITE INFOILNIATION
LI Prope ty Address: /, �,J�l 1.2 Assessors Map& Parcel Numbers
(� U r lO h� }f (/l ✓t
I.I a Is this an accepted street?yes ✓ no bfap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ET Private❑ Zone: _ Outside Flood Zone'? Municipal E/On site disposal system ❑
Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Qw ert of Reco 51: -ra Y J ox ' /f OGN'> (f 0 f��n d
�ii �Pr�Ms 2ea� Ll I 7/
�Ine(Print) City,State,ZIP r 1
9 z ° 7 I-)q hoc ,rs CATMn11 C�v�
No. and Street 'rcieplione Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Buildinkg Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specity:
Briitet'Descript Ij of Proposed Work': IS f 61
/1rr ��i(i?t�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. uilding $ 1. Building Permit Fee:S Indicate how fee is determined:
�. Elctrical C�� S ( J ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier- x
3. Plum 'ng 5 2. Other Fees: S
4. Mcchan -al (FIVAC) $ List:
5. :\lechanic I (Fire S
Suppression) Total All Fees:S
X� Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 3S 0 ❑ Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCT ION SERVICES
5.1 Construction Supervisor License(CSL) y SS�� ) r'1 2 3 13
U l r( el" Bo CNP S License Number E.cpir tion ate
Nantc o Oder
List CSL"type(see below)
No. w I street V� .type Description
l/i'1 tip U Unrestricted(Buildingsto 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Cityfrown,Stale.ZIP I M Masonry
\ RC Roofing Covering
WS Window and Siding
] U SF Solid Fuel Burning Appliances
Ih (�s q q,rI I]I' � 1 lnsululion
'relc hone Email address D Uemol:lion
5.2 Registered Horne Improvement
/Contractor(H1 )U �(�n] s -) 1111201
QfIQ" 131 -LP5 C (2Ci \ QAA, ne (�ns� TFIIC Registration Number Epirn' nDate
III Ca :my Name or HIC I cgislranl Name
�zZ to
NIO \Street A ,, d Q �� 5 _�I�C� Q Z / Email address
Cit /Town, State,Z PJ"`f, 0 Telephone '0
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...........❑
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 '�C 1 G1 ---) �� " <
t9 act on my behalf,in all matters relative to work authorized by this building permit app ication.
( (1 C�n i,--oC.�le� o
Print Owner's Name(Electronic Signature) I D to
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 this application and accurate the best of my knowledge and understanding.
o � 13
Pant Owner's or Authorized Agent's Name iectrunic Signature) ate
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 Flome Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty I•und under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
w-ww.mass.eov.'oca Information on the Construction Supervisor License can be found at www.mass.e0V/LI ns
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. "Focal Project Square Footage"may be substituted for"Total Project Cost"
° CITY OF S<Ai EM, I,'LkSSACHUSETTS
`• • BUM=NG DEP.tRTME.NT
120 WASHINGTON STREET, 3'a FLOOR
T .L. (978) 745-9595
Fox(978) 740-9846
KIJIgFRY FY DRISCOLL
T
1YOR HoNus ST.PiERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\NISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4 D licant Information (/Please Print Le ibl ' t( 11
Nat ne(Business()rsanizationllndividual : s?)'c ] G n ��eS lA•' )� \y U1 S� '�� �t`7/�.J 1
Address: n &2a�,.R
City/State/Zip: A 01CA I s Phone 4:
Are you an employer'Check the appropriate box: Type of project(required):
1.�`ti am a employer with"_ 4. ❑ I am a general contractor and 1 6. ❑New construction
.y. employees(full and/or part-time).° have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• Remodeling
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. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I 1.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [Nr0 workers' 1} ❑ Other
comp. insurance required.]
-Any applicant 1l ar checks box nl must also fill out the section below showing their workers'compensation policy inl'o mation.
t 1 u.cownsnts who submit this aftidavir indicating they arc doing all work and then hire outside contractors most submit anew affidavit indicating such.
=Contrscwn Ihut check this box must attached an additiatul sheet showing the coerce of the sub-contractors and their workers'comp.policy infornution,
l ant an employer that is providing workers'compeasadou lasurancefor my employees. Below is the polky and job site
information.
Insurance Company Name: �, I—��_�_._ ,[�
Policy#or Self-its. Lic.N: `„`V(��,�'I S� Slo 1_-)53 203 / 1 Expiration Date: 21S. 20�
Job Site Address: (O0 City/state/Zip:
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 S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ul"the DIA for insurance coverage verification. -
l do hereby certi y rurder die pains a(nid penalties of perjury tlrut the irrfonrtarion provided abuVie I rue and correct
skw;ilurc: (�/� e� gD3( CK�' Datc b
Phone 4: C� I�
Official use only. Do not write in this area,to be couipleted by city or town ofjiclat
Cityor'fuwn: Permit/License#
Issuing Authority(circle one): �.-
1. Board of Health 2.Building(Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other.
Contact Person: Phone#:
CITY OF SM�EM T%LkSSACHUSETTS
BUILDL-IG DEPARTNtE2NT
120 WASHNGTON STREET, 3" FLOOR
TEL (978) 745-9595
FA.Y(978) 740-9846
KTA(gFRT F.Y DRISCOLL
1�tYOR T -Y oNw ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY BUMX)DJG CONLMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL e 40, S 54;
Building Permit# 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 MGL c
111, S 150A.
The
®debris will be transported by:
CY) C, hf �D1(l
(name of hauler)
The debris will be disposed of in :
_ rfW 1CL,14s1
(name of
P6b x � 2OWL
(a dress of facility)
i
signature of permit applicant
date
debri>a i f dux