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4 PICKMAN ST - BUILDING INSPECTION (2) '1 �V ( The Comtnonwealth of Nfassachusetts aryOF Board of Building Regulations and Standards SAL NI Massachusetts State Building Code, 780 CbIR d Mar Revised Mar 2011 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 Appl(ed t Building Official(Print Name) Signanire. Date SECTION 1:SITE INFORMATION 1,'1/Property Address: '/ L2 Assessors Map& Parcel Numbers 1.Is Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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 ❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTION 2:, PROPERTY'O WNERSHIPL 2.1 Owner'of Record: TP fPr y c��� rbWs ys Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction-$ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition Accessory Bldg. :3 Number of Units_ Other ❑ Specify: Brief Description of ProPused Nork=: 5-L'n yr YL2tr, r�iNrXj — or oc 17 SECTION 4: ESTILNLkTED CONSTRUCTION COSTS- [rem Estimated Costs: Official Use Only, Labor and Ntaterials I. Building $ 3 S Odp I. Building Permit Fee.S ' Indicate how fee is determined: 2. E(cctrical CIStandard.City/Cuwn Application Fee ❑'Cotal Project Costs(Item 6)x multiplier x 3. Plumbing 5 y A 2, Other Fees: S 1. Mechanical (IIVAQ 'S List: i. ;;\(xh:utic.il (E'il'a S nn . Sri t tressiun) _ A111 Total All Fees:.,_ Check No. Check i\nwunt: ---Cash antuunt: _ r, Pn(al Project Oust S 3? `7 (/(/ I 0 Paid in Pull 0 Outstanding Ilal,lnee I)uo: SECTION 5: Co.wrRUCrION SERVICES 5.1 Construction Supervisor License(CSL) �1 - - 7 2 I License Number Expiration Date i J ame of CSL I loldcr In �J( List CSL Type(see below) 1K- ompb — • type Description No. and Street Q .� /Q�tJj U Unrestricted(Buildings u to 35,000 cu. ft. , r7rApe7c!Q ]`/t �4- / [ R Restricted 1&2 FamilyDwellin City/rovn, Siatte, ZIP NI \rlasonr RC Roofing Coven❑ WS Window and Siding SF Solid Fuel Burning Appliances 781-Z1v0-G�Nr� aplel�ro/5S0 X&e COK I Insulation Tele hone I Email address D Demolition 5.2 Registered Home tmp�rovepteent Contractor(Itic) N�/7 / MC Registration Nut I II ber Expiration Date C�ompan�j am r IIIC Registrant Name 14 ymphrev + 179�.crl'v / � �Do. CDr'1 No. and Street --r I address f;/1 M 9 'o/-?� 4/4_ ©/?Q7 76/-71W-i a Ci /Town, State, ZIP Telephone 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 .......... 0 No...........❑ 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 /?I7�/l D� / ,e?N ro to act on my behalf, in all matters relative to work authorized by this building permit application. Jt?f� I a!20fraw-S � / Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' 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 application is and accurate to the best of my knowledge and understanding.' / Print L)lYn• ; Authorized.\;ent's Nantc(Electonie Signature) Date NOTES: I. :\n 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(HIC) Program),will not have access to the arbitration progrun or guaranty find under M.G.L. c. 142A. other important information on the IIIC Program can be found at www.mass. uvloca Information on the Construction Supervisor License can be found at www.mass.•nt�_dL 1 When substantial work i, lanned,provide the information below: Total Boor Brea(sy. R.) - ��I _(including garage, finished basentent/attics, decks or porch) . .) Habitable room count trots; living area(sq Niunberof tireplaccs-.---------- Number ufbedrooms _------_--_-- Vuml;crothathroonts �_ Numberoflmlbb:ulis -- — I'cpc `:uinbcr of deck,/ pnrClu; I*%peoFotolin" ;yucnu / - __-- finClt;cd ----- _ ... . p' ll t. `fo!d I'tojtct '�yunic Prot lge" in t4' 110 ,uh;titut I f�r"I'ni.il IhojCa 11r;t" . �' ';"t"","t - aro- . m k...., - .rx, ev a..,,.. - -.r•a ",mAx^^ a t,G-m .. .....gx 77 .r CITY OF S�uE,%1, lLXSSACHUSETTS BuimIN G DenRT MNIT= 120 W.-61-11INGTON.STREET,3 F[.00R ' TEL (979)745-9595. F.1x(978)740-9846 KUNME t EY DRISCOLL THO3,US ST.PIERRs MAYOR DIRECTOR OF Pt;BLIC PROPE1t7Y/BUIIbLNG CONDUSSIONER Workers' Compensation Insurance Afl7davit Builders/Contractors/Electricians!Plumbers Anoncant Information Please Print Le l o D Nance(Busitxss:Organizatiorvindividual) Address: omDAr eM \, /� 7/(Pf/�i ` City/State/Zips C0 t X Phone#: 7571— f —6 o211D >y Are you an employer?Check the appropriate box: 'Type of project(required): 1.❑ lama employer with, 4. ❑ I am a general contractor and I 6. ❑New,construction -ntployees(full and/or part-time).' have hired the sub-contractors 2.t�Jl 1 am a sole proprietor or partner- listed on the attached shun:t 7• 0 Remodeling t .hip and have no employees - Thtue sub-contractors,have a. ❑ Demolition working",for me in any capacity. workers'comp insurance. , g, Building addition [No workers,. insurance 5. We are a�corpomtiort and its, 10.❑Electrical repairs or additions , required.)` officers have exercised their,.. 3.0 1 am hotneowner�doing all work right of exemption per MGL t I.�Plumbing r`cpairs or additions t myself.[No workers'comp. e. 152,q l(4) and we have no 12.❑ Roof repairs insurance required.)t. employees.[No workers'- • I`. 13.0 Other comp ins rlince required.).* •any applic ul that chocks box sl musralw fill out the section below showing their worlun'compertsub s pnlivy mformat(on.� t I h.meowm"who submit this affidavit indicating they are doing all work sod then him outside emaruttms must submit a new affidavit indicatinasuch :Commcton that check this box must attached an aldiGenui sheet shuwmv the name of the tubeoMnctuts and their warkt rs'comp.put icy information.. _ !um.an employer that Is providing workers'compensation htsarance for my emplayem BelowJs the policy and Job site Insurance Company Name: Policy 4 or Self-ins.Lic. 6: Expiration Date: jot-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.covemge as required under Section 25A of MGL c. 152'can lead to the imposition of criminal penalties of a tine up to St,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. Ile adviw:d that a copy of this statement.may be forwarded to the Office of - Investigations of the DIA for insurance coveroge_verification. l do hereby eertify under that 1 s w lie yl{ of perjury thor the iirformurlon provided ahuv is i us and correct 1 / 3 q'�. t I Date' Phone 0: Ojrcial use only.. Do not write in this urea,to be coutpleted by city or town ofjielal City or'rown: PermitR.lecnse fi Issuing Authority(circle one): t.Bourd of Ilealth 2.Building Department 3.Cityffown,Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: ___ _.... __ Phone it: j may„ ,. CITY OF S:LI. Nf2 NL1SS:wHUSETTS \ F ), Elt:tLDLVG DEPAIMLENT ;C'w •j� 120 C9.ISHLVGTOv STREET, 3'"FLOO;t �h y IFL (978) 745-9595 ;<l1COE4L.EY D2ISC0[l AUY(978) 74t-9344 IN,L1Y041t I1t0b443 ST.PIERRB DRECTOR OF PLOLIC PROPEl1TY/BCILDLVG COIL\llS5IO,VER Construction Debris Disposal Affidavit (required for all demolition mid renovation work) In accordance with the sixth edition of the State Building Code, 730 C�bIR section I 1 L5 Debris, and the provisions of tMGL e 40, S 54; Building permit Ik 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 ttifGL c It I, S 150A. The debris will be transported by: v (name of haute I The dt:b isI will be/disposseed of in : (name or racaity) mot . si3 r ofpermit applicant �y �3