5 POND ST - BUILDING INSPECTION (3) Silo 60 L\n 'the Commonwealth of Massachusetts w aG #
V, 1 Board of Building Regulations and Standards SALEtiI
Massachusetts State Building Code, 780 CMR 101b DEC 2 Rijs*PWO
' Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Fmnily Dwelling
This Section For Official U e only '
( ;Buildingermit Number: led:Official(Print Name). Signature• ' Date
A SECTION Ii SITE iNFORtNIATIONrty Address: S�Un(�S t Cam/ 1.2 Assessors Map St Parcel Numbers
I.1 a Is this an accepted streetl yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Coning District Proposed Use Lot Area(sq R) Frontage(0)
1.5 Building Setbacks(11)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Check if es❑ P P Water Supply:(M.O.L c.d0,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private O _ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTYOIVNERSHIP!
--------------
2,t O vnerr of Record: r�p Q f 17 b
1n L Vw
�5me(Print) _ City,State,ZIP
B gXq 713 7
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED IVORW(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ j Alteration(s) ❑ Addition ❑
Demolition ❑ AccessoryBidg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed 1Vork':
P P
SECTION J:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I Building S I. Building Permit Fee:S—ZE Indicate how fee is determined:
❑Standard Cily(fown Application Fee
2.Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing t ; S 2. OtherFecs: S
t.Mechanical (FIVAC) S List:
5. ,Vechanic:d (Firs S total All Fees:S
ression)
Jh " 7� Check No._Check Amount: Cash Amount:
G.'f tal Project Cust: S tJ ll V ❑Paid in Full 0 Outstanding e
L to ziiiij S r t C7 lq,(o D
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) a 5�-07-3832
J eO k di y�t J`,L,Vrr 4 License Number Expiration Date
N;mic of CSL Holder List CSL'rype(see below) V
`�r iiwieL fermi Type Description
Nu.and Street -'
U Unrestricted(Buildings on to 35,000 cu. It.
R Restricted 1&2 FamilyDwelling
Cityfrown,State,ZIP M Masonry
/fie g dod sl IYIA (J/��d RC RooWindow
Cnd Sin
st
WS 1Vindow and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Tcle hona Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) y
�7- �r-� i t ��L�
V 6 kt d i�.(/ice HIC Registration Number Expiation Date
111C Cumpan Name or HIC Registrant Name
17.s,y `-e L Ter*
No.and SuV%e 12,1�'/ 4 � ���Z8/3S� Email address
City/Town,State,ZIP T Tale hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT'(M.G.L.c.ISi.§ 2$C(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...........O
SECTION 79:OWNER AUTHOR12ATlON TO BI COMPLETED WHEN.:
OWNER'S AGENTOR CONTRACIPORAPPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
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�llW applcglion is true apd' aourate to the best of my knowledge and understanding. /
Pri) orn ef's or Autliorrzed Agent's Name(Electronic Signature) Date
NOTES:
1. 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 Home Improvement Contractor(HIC)Program),will nut have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program can be found at
www mass�xn�'oct Information on the Construction Supervisor License can be found at AAAA112ss.eos:'dns
[2. When substantial work is planned,provide the information below:
ta) tloor area(sq. ft.) (including garage,finished basemenNattics,decks or porch)
oss living area(sq.ftJ Habitable room count
mber of fireplaces Number of bedrooms
mber of bathrooms Number of hal6baths
pe of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. `Total Project Square Footage"may be substituted for Total Project Cost"
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
l Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /� Please Print Legibly
6 Business/Organization Name: uclih A"N Co n J T-, PLU3
Address: 1 -7 l Low-il✓L �T t
r
D �ba2
City/State/Zip: l� �O +A- Phone#: �, `�7 " 57-- 6 ;1-1
Are yqa an employer?Check the appropriate box: Business Type(required): -
1. I am a employer with 0_employees(full and/ 5. ❑Retail
orpart-time).* 6. ❑Restaurant/Bar/EatingEstablishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(me].real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing 1
no employees. [No workers'comp. insurance required]* 11.❑ Health Care ekAOU'e, fZ� r6c e
4.❑ We are a non-profit organization,staffed by volunteers, -{r(14ri { s
with no employees. [No workers' comp. insurance req.] 12. Other��,yV�p t;(p,i KI -Gj$/1 1 3T r 1,,
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I ant an employer that is providing workers'compe cation insurancefor my employees. Below is the policy information.
Insurance Company Name: L_ IJ C 2 , ` ,o
Insurer's Address:_ Fb[R S r:�t.)D a k
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date: I -
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 MOL 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 DIA for insurance coverage verification.
I do hereby certify,under thepains and penalties of perjury that the information provided above is true and/correct.
Signaturer�7�V� i� 4/��re7w✓ Date: p--
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License# '
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.inass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15
CrffOFSALEA MASSAGiMn
im w�aysaasr,.Y°A,o�
MMUTInFrIg. XL Fi1x 7i49F�b
MAYOR 7�4S7.P�
a��uc /stuunaaaraoasoc�
Construction Debris Dispose/Affldovit
(required forall demolition andrenovation work)
In accordance with the shah edition of the State Binding Code, 780 Wk Smft ili.S Debris,
and the provisions of MGL o0Q S 54; Building Permit B is Issued with the
condition that the debris resuitbtg from this work shall be disposed of in a properly ra:ensed
waste depasit fadlityas defined by MGL c illy S 15k
The debris will be transported by.-
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date