10 PICKMAN RD - BUILDING INSPECTION (2) C� A �S
\ _ :1 Ilti Cbnunumvualth of�I:usarhusclls
Iluard aflluilding Regulations:md Standards CI VV OF
s{L,, �1;tss;trhusrtts Sync Building Cudc.'780 CNIR
Building Permit Application To Construct, Repair. Reltuvate Or Demolish a 1?,,1 m o I 16u
011v-ur Puv:•Piunrl:•Un ellir:•y
This Section Fur Otrcial U e Out /
Building Permit Number: Date \p icd:
11111lJmy 0111v:al(Print Massa) t
Signature Uutc
SECTION 1: SITE INFORISIATION
ropfr1i- ;a'r [ 1.2 Assemors,Slap& Parcel Number
1.la Is this an acre led street? es no Slap Nunther Purcel Nun:lur
I.J Zoning Information: 1.4 Property Dimensional
Lmuny District 1'mpund lJv—y LIII AIrY(Y III 4 Pronluye(1l)
1,1 Building Setbacks(R)
Front Yard SiJv Yards Required Fruits
Rryuircd ProvidedRryuircd Rear Yard Provided
1.6 Water Supply:(M.G.1.c. JU.§54) 1.7 Flood lone Informetlont- -
2.1 1.a Sewage Disposal System:
Ih:bllc Private O Zone: _ Outside Flood Zone?
Cheek If es0Municipal On site disposal s)stem O
RTYOWNERSH
,ant y= r TOwnert of Record: SECTION 2: PROPE M
C Ind r,- I S$ 1�1 �1 Mune( it)
c�(ACA v 1 <uy stale.iIP
17 a7a- 3 Nu.unJ Street relrphuna
F.:nutl AJdrcYs
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existitsy Buildiny❑ Ovvner•Occupied EF Repairs(s) ❑ Alleration(s) (3 Addition 0
Demolition O Accessory Bldg. O Numberof Units 1 Other O .Spccity:
Bri do f ro osed Work-:
Q
SECTION a: ESTISI.ATED CONSTRUCTION COSTS
Item Estinmrcd Costs:
L.:hor;u:d.\laterialt) Oil NI Use Only
I Building S S O O I. Buildiny permit Fee: S Indicate hovv fee is determined:
'. Llecirieal s ❑Standard City'Tovvn Application Fee
I 1'lunihiitg S ❑Tulal Project Cust'I Item 6)s mulliplier v
=. Other Fees:
J. \ledi,mie.d ill\ \('I j List:
—LL— rwal.\II Fees: S_
. : 1'ntal Project Cnvt 'S ,,S'OQ
❑P.iiJ m Full Q IhusCmdiny Rdl.mee Due:
a� 33
SE("II()Nt; ('(MVil'Rticr1ONSF.RN'1('f.S /
p_q I b 48-. . . � -28/1`}
t,l ('unslructiuu - lle iur Licmue(CSL) I „r;aiou U•ue
I
llit l'SLI)Ix:l,ecbeloal.-_,�__—..._
al.
N,,. .utJ street _.-_. .--- l I I4tresuictcJ Illuddin s Ii l0 11•tl0U ILI
g q 9 K l(c,IrleteJ IX r.unil I)„cilia ,
In
l'ini I."Im.State.LII' Rl• H,wlin Cmwrin
µ'S N'indu,r.wJ 3iJin
•- 60yl SF S01ij 1'ucl lluming Appliances
tW n,�.QCDr,�StRV..`F;UN I Iniulmimn
979 2_zs T D 1 Dcnwliliun
f'elc hmle entail aJJrcai
159-I — 2s 13
S.1 Registered llome Improvement Contractor
(HIC) IIC'Iteghtruuun Numher Ltpinuiun I)ute
/h0 �a�
•�'oN T13 co�✓stK✓'f-d✓.Cv a't
ill(.*C'oniD.42 L ^r I IIVCd(cgl%IrUlll Naltte Ema1l aJJrosi
No. wtJS M Oi97D 77F 273 60
l' �1n'1 711� 7ek hone
CI /Town. State ZIP
SECTION 6l WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C. IS7.� 35C( )
Workers Compensation Insurance affidavit must be completed andsbmi ed with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit
SignedAflldavitAttached? Vas ••••••••••
No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE C0111PLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I.as Owner of the subject property.hereby authorize
to act on my behalf,in all matters relative to work authorized by this bu ding permit application.
t ivtt CAerwi0 oteZ
Print Utmer's Nwne(Electronic Sianutunt)
SECTION 7b:OWNERI OR AUTIIORI2ED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the information
s true and accurate to the best of my knowledge and understandng.
contained in this application' i 4 /2
�an/ C She2✓oo Dalc
Print U„ner'i nr:\wbonnJ,\gun s Nanw II I un nIc ligntUir�)
NarESt
I Iiln lot registered in the building
I per mttto do hiclur lHIC) Programin ill!u'`havehaccess to therlbitrditiuntlractur
prog`aln or guarl`Iiyl'und under un he Conlslructioa Supers sot License er impuriant l .nn 6e found at ion on the C Program c'ntbaltbunJ r
ation
\\hen substantial twrk is planned. pro%idc the inlonmation below:
I ine)uJing gang(. tinished basetnent attics.Jocks or porclu
rolal Iluur area 1 W 1L1 . --- habitable room emult .
._
(;n,is lis u IreaIstg y I).) .... � Vunthcr pj beJru,nni -
,iumiheruflucplaces ,. ... _ Number ill hall,h,uhi A
\un,her,,lh:uhrvmns , . - VumhcralJaki p, rches
I,Ilk:,ithe.uutg >>,tci❑ I'nckneJ ell
I� I hay t t m / �
t I -f,q.il I'nlcct tiynare Paatage' nta) Pe ,uh,Im�0.J hie I, I•d 1 r I t C 'it" / 1 6
CITY OF S'kL.EN1. l SSACHUSETTS
Bt LMNG DEPAR-MENT
f� • 120 WASHNGTON STREET, 3° FLOOR
`-0 TEL. (978) 745-9595
Rja(978) 740-9846
KIJiBERLEY DRISCOLL
MAYOR THO\fAs ST.PtERRa
DIRECTOR OF PLBLIC PROPERTY/BCDDL\G COMWSSIONER
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 111.5
Debris, and the provisions of MGL c 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 I50A.
The debris will be transported by:
1
(n me of hauler)
The debris will be disposed of in
(name of racilit )
Y
(address ot'racility) A
-
Signature of •rmit applicant
-----7---A`-t—Z --
date
Icbri>olt:d,x;
r 1
CITY OF Siu-F—m, NWSACHUSETTS
13UL DING DEPARTNUH-NT
120%M"HLNGTON STREET, ate FLOOR
" T EL (978) 745-9595
FAX(973) 740-9846
KI�BERLF DRSSCOLL
MAYOR THOMAS ST.PiElaRs
DIRECTOR OF PUBLIC PROPERTY/BUII.DING CONLUISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractor.v/Electricians/Plumbers
Ariolicant information �j Please Print Legibly
N;IlnC(Raines.Organizatiarvindividual): A/J J/X pq/y
Address: _ 7 C141Z/L q - e—
`
City/State/Zip: ,S4 /Cirl M4 61972 Phone #:
Are you an employer?Cheek the appropriate box: F9. C]
roject(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1
en loyees(full and/or part-time).' have hired the subcontractorsNow construction
2. am a sole proprietor or partner- listed on the attached sheet odeling
ship and have no employees These subcontractors have olition
working for me in any capacity. workers'comp. insurance. ding addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their trical repairs or additions
J.❑ Iran a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or udditions
myself. [\o workers'camp. C. 152, §1(4),and we have no 12.❑ Roof n pairs
insurance required.) It employees.[No workers' 13 M 6her �>•(
camp.insurance required.)
•Any applicant dur eheroW box el must alto till out the section below showing their workao'compensation polity inibmation.
'I r,",ownes who suhmlt this mndnvit indicating they am doing all work and then him outside contractors must submit a new an?davit indioling such.
=Cuntmctun that cheek this box must anachod an additiutul sheet showing the nerno or the sub-contractors and their workers'comp.policy intomaotion,
lam an employer that is providing workers'compensarlan insurance jar my employees Below is rbe policy and jab site
injnrmudom
Insurance Company Name:
Policy 4 or Self-ins.Lic.b: Expiration Date'
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
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 S 1,500.00 andbur 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. Re advised that a copy of this statement may he forwarded to the Office of
Ilvestigutiotu atlhe DIA for insurance coverage verification.
f do hereby t'errijy a tder tlt pains uad penalties of, rrjury'Bar the fnjarnrwlan provided ubave is true and correct.
SL„ .I tr . Data_��99 �Z
Phone 4 —SD 417
OJJicial use may. Do not write in this urea,to be completed by city or rove gJh•laL
i
City or'fuwn: ._ Permtt/Llcenre q_ I
I.csuing Authurity(circle one): --- -------
I. RUard of IleaOh 2.Building Department .).Cifyifuwn Clerk 4. Electrical Inspector 5. Plumbing inspector
6.Other
Contact Person: Phone 4:
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property line (fence)
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