4 PICKERING ST - BUILDING INSPECTION f— '"t UR TWO FAMILY DWELLING
d'of6 state --- -- _--_ -
F3oord of!>u ilding Regulations and Standards
Massaclt use(ts Slate Budding Code
780 CMR
- ,,�,j/ �. . - ec��ICAT1ONiYit:ON - - ,-. -^•"� --_ ._ -.
\I"I / R,RENOVATE H A ONEURiWO FA1AILYDWELI�NG
This Section for real U Only
Building Permit Number-
ate lss
Signature (n
Bm7diag Comuiaioocr/�Ilaspodor T
Da e
SECTION 1 -SITE INFORMATION
LI Prope Address -
JJ Assessors Map+Pared Number
_ mapNnmbcr rarmnn�nbfr r' -
13 Zoning Information
r 1.4 Property Dimensions
Zoning Da Pr^Poxd Use(Nn of dwd-G/ __
Lot Am Fmnb Ceifo
IS Building Sc[ba<ks
Finat Yard - Side Yard
Required Provided R Rear Yard
.-. cgnitcd�„ .. P rovided Required Provided
1.6 Water Supply-C.L.c-40.S 54. 1.7 Flood Zone info matioo
Public ❑ Zoa<
I A Sewage Disposal Systems
Priv:f< ❑
1.9 Special Prrmit __ M A ❑ Municipal n Septic system ❑
1.10 Old+Historic Commission 1.11 Conservation Commission
Date Filcd WA ❑ Number
WA ❑ Number N/A
ECTION 2-PROPERTY OWNERSHIP/AU7HORIZED AGENT
21 Owner of RCCOraS
� Addrera far Servrc(
tort
Y.
z- Oozed Agent
S)77 N
Address it
ECTION 3 CONSTRUCTION -
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nama Pi DZ
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3�- ister<d Hom<Imp vement Contractor
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Ad
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ECTIO
Orkers 4 -WORKER'S' 'INSURANCE AFFIDAVIT(MG.L c.1S2-S 25c(6))
ovides Cs affidavit
Compensation Insurance affidavit
Provide this affidavk will must be oomPlcted and submitted with thisa
thttderial-0f-ttlei Jtlination..-Failure-to 'ss"-ucv or-me-but f mg Permit .
igned Affidavit Attached Yes__...
No._._
ECTION b-DESCRIPTION OF PROPOSED WORK(chock all
<w Cons[ructioo apPlicablo)
❑ ErisiGag Building ❑ Repair(s)
Alierltion(a) Additiao Acccswry Bldg, Demolition. ❑
Brief Description of Proposed Work: i 6 I
oclP a"n wl Sr� Grv �
t
ECTION 6-ESTIMATED CONSTRUCTION COSTS
I[tm
Estimated Cost(Doff") OFFICIAL USE ONLY '
1. Building
_ (1)Building Permit Fee
.Ete<tical
�. Multiplier
(b)Estimated Total Coat or
.Plumbing
�• ��—• Conrtrnction tram(6)
000, 00 Building Permit
-Mechanical(IiVAC) ^
Fire Prottctiou
Tot4l=-(i +2+3+41-5) L7 (/
0 00 O Chttf:Nnmbcr
ECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
f S1ttcf�
hereby authorize �L as Owner of the subject property
atters rel to ork oath "zed - to act on my behalf. In all
y+tltis.building Permit application.
Sigva ar ----------
'Dale
- ECTION- -- - T -----_ --------- --._ ___
-OWNCR/AUTNO - _ �� --
--- RIZEO AGEttT:DECLARATION
ereby declare thatthe statements and Information on the foregoinga IilztionAmElwWrlAuthorked Agent
T my knowledge and belief. PP true and accurate to the best
igned under the pains and penalties of perjury,_ - - -
S [arc of 'n.er/Agcut --�R`J_L/ik�
ECTION 8 -NOTES AND rvpLANg770NS
Fees: The amount of foea shall be$151$1000(13u11ding-$10;Wiring:$3; Plum bin
the work Performed and materials used In conjunction with tills g-i2)based on the total cost of
Minimum Fee: $30 1 f>°mlit as estimated by the Building Official.
t,
The Commonivealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston MA 02111
_ ' < www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 9 Please Print Le gib
Naive (Business/Organization/Individual): s{y/
Address: S
City/State/Zip: D Phone #: - off
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 1 4. 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. I[QRemodeling
ship and have no employees These sub-contractors have g_ E Demolition
workingfor me in an capacity. employees and have workers'
Y P tY� 9. ❑ Building addition
[No workers' comp.insurance comp. insurance.#
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3. I am ahomeowner doing all work officers have exercised their I LEI Plumbing repairs or additions .
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repo rs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
'Any applicant that checks box.41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such-
ICorim ctors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'camp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic,#: Expiration Date:
Job Site Address: 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$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 DU for insurance coverage verification.
I do hereby der the pains and enalues ofperjury that the information provided above is true and correct.
Sieuature Jy i Data,
Phone#:
Official use only. Do not write in this area, to be completed by city or town offrciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
_ w
CITY OF S.UY.,Nf, &L-1SS.-ICHCSETTS
13LI DLYG DEPARTMENT
120 WASHNGTON STREET, 3'o FLOOR
` T-EL (978) 745-959S
FAX(978) 740-9846
KI\®ERLEY DRLSCOLL
MAYOR Tto.%w ST.Ptsxns
DIRECTOR OF PUBLIC PROPERTY/BUIIDLNG CONWISSIONER
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 l 11.5
Debris, and the-provisions-of-MGLc 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:
�P /
(name of hauler)
The debris will be disposed of in
lV tioL2Id-
(name ,dt,
(name of facility)
(joress of facility)
signature of�perrnit applicant
l? �i11.2
date
Icbnaai(J•w