10 PORTER ST - BUILDING INSPECTION (3) Z 1 c) - t L4 4�2.325
The Commonwealth of Massachusetts
* � Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR S
ALEM Revisedd Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dvelling
This Section For Official Use Only
Building PermitNumber.� - Date plied:
3
Building Official(Print Mane) �t Signature Date _
L SECTION [:'SITE INFORMATION
I.1 rop�rMy�G.re�f•I'GG Z 1.2 Assessors ivlap& Parcel Numbers
L la 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 I) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.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 i f yes❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 OwAeri f Reco d: � � �'
/O �or �nalvm/'r�,yr lrvff SCilernJGt- O(ci
me(Print) City,State,ZIP
10 j'o��ir Sf-- &17�°i(,,k 262S
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building Ef
Owner-Occupied ❑ I Repairs(s) Alterations) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': - /` yA p•? A/) Y/eK t-t q S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials) Official Use Only
I. building $ (PpU,'''� I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee:
2. Electrical $ -
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: SL \ 7r
4. Mechanical (HVAC) $ List: , U
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount
6. Total Project Cost: S 7,/o pp• p paid in Full ❑Outstanding balance Due:
10 11 CKET,,t,3
SECTION 5:, CONSTRUCTION SERVICES
5.1 Construction S/u
�(� pjervisor License(CSL) 6 S Illd Z 3 2j/t�.
PV4rr/iD r7, Vl k's License Number Expiration Date
Name of CSL holder
List CSL Type(see below)
No.and Street "type Description -
�a U Unrestricted(Buildings up to 35,000 cu. Il.)
rr �� R Restricted 1&2 Runily Dwelling
City/Town,State,ZIP ibf Masonry
RC Roofing Covering
WS Window and Siding
r� SF Solid Fuel Burning Appliances
SoD C132 fj�/L F//f17- ✓�/1 H/C27lLf%l�r I Insulation
Telephone Email address D Demolition
5.2 Registered Home mproyement Contractor(HIC) 1�P ��! D 2tj ZOIZ
I>UfFff HIC Registration Number expiration Date
HIC Name Col or IC Registrant Name r
i� /�� Gi�v-� f'har�D1. brr�os'.�G/��l.co �-
No. d tree[ (/Z Email address
Gt .tt^ 71f-7 2 6if fly
City/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 Is§uance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........9-�-
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 r/�q 13,,bGt it e,
tq act on my behalf,in all matters relative to work authorized by this building permit application.
1
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 true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
L 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.'oL yioca Information on the Construction Supervisor License can be found at www.mass.sovAlns
'-27 When substantial work is planned,provide the information below:
"total floor area(sq. ft.) (including garage, finished basement/attics,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. "Total Project Square Footage"may be substituted for,,total Project Cost"
K �
CITY OF S.u.E1) I, NLkSSACHUSETTS
BUILDIING DEPART-M&NT
120 WASHQVGTON STREET,3"'FLOOR
T EL (978) 745-9595
RitX(978) 740-9846
KIJBFRT EY DRISCOL-L THO%WST.PiERRB
MAYOR
DIRECCOR OF PUBLIC PROPER'IY/9l:II.Dt:`IG COSLtiIISSIONER
Workers' CotnpensatIon insurance Affidavit: Builders/Contractors/Electricians/Plumbers
,k i licant information Please Print Legibly
Name(OusiixsiUrgani:atioulndividuai): r/yr��j
Address: /l DG/L��Gn aql -
City/Statc/Zip: 74l444 IVA.- 1F(4V Phone11:
Are you an employer?Check the appropriate bo • Type of project(required):
I.0 I am a employer with 4. 1 am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time)." have hired the sub-contractors
2.0 Into it sole proprietor or partner- listed on the attached sheet t 7. .0 Remodeling .
ship and have no employees These sub-contractors have a. ❑Demolition
working,fur me in an capacity. workers'comp.Insurance. 9 Y p ❑Building addition
(No workers'comp.insurance 5.'0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152,§10),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 13.0 Other
cump:insurance required.).
•Any applicant thasehucltabaxtt must also rill our the Maim belowshowing their wake
n'compensation policy intomadon.
'I hsmvuwnets whosubmil this affidavit indicating they am doing all twrk and then him outside contnctae must sutnnil a aaw alildavil indicting such.
$Iummotun that chalt this box must mtachod an addidunal shout showing the none of the sub-contractors and their workers'camp,policy Inrommeon.
l am un eatplayer that Js pravfding workers'contpetuatlon insurance far my employeez Below is tie policy and fob site
brfarmarlam /,J/
Insurance Company?Iamcn Rlmli/A G I ��f' (',a
Policy U ur Self-its. Lie. 4:� Lt hd rAlA Expiration Date:(
Jub Site Address: /(l 6 yr/� ' City/Statr/Zip:
mtacb 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 undlor one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a line
of up to S250.00 a duy against the violator. lie advised that u copy of this statement may be furwurded to the Office of
Invesligmiuts ufdte DIA for insurance coverage verification.
l do hereby certify fill r thpyubtt uJ peuu/r(at ofperjury that the hilbri attlar proof led above is true and c•orrre6
`J 3 13 Sicnamrt: Data:
Phone,4:
UJ/ic ial use ants. Oo not wriu its this area,to be completed by city of town afflc luL
I
City or'ruwn: ..... Pl'rmi1JIJcen1e.4
Issuing,%ulhurily(circle one):
L Board of health 1. Iluildinq Department 3.Cilyi rown Clerk a. Electrical Inspector 5. Plumbing Inspector
6.Other _---- --—.- _
i
Contact Person: Phone 11:
(