28 PRESCOTT - BUILDING INSPECTION --- I lie C'onununarallh ul'Ibl:usaehuscus
n 'la Board ut Building Regulations and Standards CI'I'1' OF
I' /ll sr ',✓✓ Ntassachtuetts State Building Code. 7SO CNIR -S.\LI:,\I
ir,•ta.,,d lr„r ni
Building Permit Application '1'o Construct, Repair. Renovate Or Demolish a
One- or rtvu-Piunily Dn ellirq
This Section Fur 011110al Use Only
Building Permit Number: ate Applied: _
/411-il 1 � �
Building Official(Prim N;une) Sign rc D la
SECTION I:SITE INFORMATION I
1.1 Pro arty renstreet?) ,es
E[ol'41AArrlva
ssessor.Hap& areal Number
I.la Is this an acce leno ulnher Parcel NumbrI.3 Zoning Informat roperty Olmenslons.
Coning ilding (fq II) frontage(11)
1.1 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Reyuircd Provided Reyuircd Provided Required provided
1.6 Water ply:(M.G.1.c.JD• §34) 1.7 Flood Zone Informatlomt 1.✓t Sewage DisposalSystem:
Ihabhc Private❑ Zone: _ Outside Flood Lona7
Chock if es❑ Munieipd O�Dn fife d11pUYYI Y)AICIn ❑
ECTIONI- PROPERTY OWN RSHIP'
era of fgrd�,
N;tnte I PPri�nt) City.Slate.ZIP
No.and Arcd �Iqhune bmail Address
SECTION.): DESCRIPTION OF PROPOSED WORk;r(check all apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterationls) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Spccily:
Brief Description of Proposed Work-:
m
SECTION 4: ESTIMATED CONSTRUCTION COSTS U6
Item Esfintaled Casts:
I Labor and.Maltrials) OffIclasl Use Only
). Building S 1. Building Permit Fee: S Indicate how f'ee is determined:
'. Electrical S Standard Citffussn Application Fee
11. I'lunlhiltg S ❑Total Project Custll lien,6).xmultiplier -
_. Other Fees: S_
J, \ledt.mic.d ill\ \('1 S List:
�� \Iechaniall (Firu
till„f eiLUn) rohal \II Feev S
n Ibtul Project Cost: S ('heck No. —<'beck Amot"It: .
G BOO 0 Rid in Full ❑Oufst,anding 11.11.mce Due:
SE(`I'ION S: ('ONSI'RUCTION SERVICTS
5.1 ('oast action Supervisor License(C'til.) _ ___ 1l`
�GL I icema Nuulher PNpirilio/u I •-
l isl0L —
< h`PC )eicriplion
No. an�r U --..-'.-_ 11 1lnm.,trictcd I11midin is ti it 14.111)2'it 11
—.. . _— R Re+Iricl¢J Idl'? 1'.uni1 Dwellin .,
_ \I \bison
l'il)i foe n.
RC Rtrotin ('ol Grin
µ'S µ'indow•nd Sidin
' SF Solid I•llel numing Appliances
I Insulation
o — U 17c1nu1ition
laic Iona I'.nwiladdres
3.2 R gistcred Ilume Improvement Cuntr ctor(HIC)
i icy -
�• ��• G IIIC'Registration Number 1' piral n Data
I IIC Company Nanw ar I Ill Rc it am Name
2 it N limail uJJrcis
Nu. w Sd ct� 9�'11-6 C,/Z
i ITown.St a ZIP
SECTION 6:WORKERS'CODIPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 162.1 25C(6))
Workers Compensation Insurance affidavit must be 59mpleted and submitted with this application. Failure to provide
this atlldavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes .......... No•••• ClSECTION 7a:OWNER AUTHO RI ZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
I,as Owner of the subject property.hereby authorize
rJr4e.
to act on my behalf,in all matters relative to work author zed by this building permit application.,
�M
Print Uwner'tl Name(Hleeuonle Signulurc)
SECTION 7bc O\VNERI OR AUTIIORI2ED 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.
Iu Uwnar'i ur:\ulhorveJ,\peal i N,una Il.lutruty�\ignnunl
No r¢s:
I. .\n Owner who obtains a building permit to do her own work,or an owner wha hires an unregistered contractor
(lot registered in the Hume Improvement Contractor(HIC) Program).will ea have access to the arbitration
program or guaranly Fund under\I.G.L. C. 1 J_'.>. Other inlpurtant information on the HIC Program can be Hound at
t,,,,1 n ,n. �„ ,•, I Information on the Construction Supervisor License can be found at tt �`� 1� •1" >:'� 'Itt'
�• \\'hen substantial work is planned. provide the in(uI inctluding garage. finished basement attics.decks or porch)
rota) flour area uy. 11.1 . _-- `
(iroii liv ing area lsy. IL1 __. _._ _-.. . .
Hubifable room count
_ - \umherotheJro.nns
I \umber of fireplaces .. _- ._ \umber of half h;uhs
\oniherol'hathroolns . . - . . \unlherofdceks, porches
I\pe othc,uing ;),{min I'.nclaicJ . .01'en
l\pa, 1 e0P1111y i\.' ell)
t. "1\�IAi 1'mjecl 1tl llarC haawga'• .... he jibstitutcd fiir 'folal I'rnfeO ('Oil"
CITY OF S.t -ar, NLISS,WHUSETTS
JLMDc,4G DEp.1 -M=Nr
I'0 �O-QHNGTON SrXW, J A}ZOOM
rX 1973) l4l-9S9S
UJ®ERLBY DALSCOLL FkA(973) 1;&9S44
.titAYoA Mown ST.Pt><JtltJt
DIXEcro4 0/pL BLlC PROPEATY/RanLNG COAL\/I31lONEJ,
Construction Debris D(spos21 Atfidavlt
(required for all demolition and renovation work)
In accordance with the sixth edition ortheSeat@ Building Coder
Debris, and the provisions of MCL o 40, S 34; 180 CUR section I I I.J
9ijwork
g permit Atis issued with the condition that the debris resulting 1 +om
1 1 1 wui, S I JOA.
I shall be disposed of in a properly licemed warts disposal facility as defined by NICE c
The debris will be transported by:
2 �
(name of Hauler)
no debris will be disposed of in :
(name of cilliy) —�'
IiJdraaaff„�hiy—j�—�
tn�nrreaf,;rJPPI,,:jnt
'�,a
CCI'Y OF S,Ulm NWSACHl;SETTS
1 UL'ILDING DEP,k AT>IF—NT
.•j, ` r�:'� 120 WASHNGTON STREET, 3'a FI.COA
Rlix(973) 7 RI.9846
'<j�tptliLEY DRISCOLL
AALYO:t 'MMUS ST.PIE,a)t8
DIAECTCRCF PUBIC PROPERTY/HULLO NG CMWISMONER
Workers' Compensation Insurance Aff1davit: (3uilden/Contractorv/Electric(ans/Plumbers
1 7lleant Information Iea.re Prjn Lenibi
�Ilttnc IDueiix,oUrganuatian.individual):
CityrStatc/ZiP: PhoneN
,\re you an employer'!Check the appropriate basi 'rype of project(required):
1.(] I am a employer with 4. ❑ I an a general contnmot and 1 6, Now construction
vnplaycea(fLll and/or part-time).• have himdthe subcamnctara
2.0 1.111113 3010 propnctor or parinur. lisrud on the attached.vheul. . 7• Cl Remodeling
ship and have na employees These •ub•eonlraeton have I. 0 Demolition
working Air me in any capacity, w ars'camp.incurrence 0. DuilJin addition
i No workers•comp, insurance 3. a are a corporation and ib g
required.( officers have mterelsed their 10.0 Electrical repairs or additions
3.❑ 1 a,n a homeowner doing all work right of caumption par MGL 11.0 Plumbing repuirs or udditions
myself,(No workers'sump. c. 152,41(41,and we have no 12.0 Roof rope irs
insurance required.( t employees.(No workers' 11,0 Other
cumµ insurance rcquimd.j
,.1ny applls:ati dW vhwYr but$I must AW 1111 out In,wctiue balaw showing(hair••Drum'camrrnudun puliuy inn,tvnutloA
1(,vevuwAvtwho,ubn,lt ibis allidavit indiuling they are doing all.wrk and then hire",,ideeanlreetore shot mhrnle a new ullldavil indloring u),
Cmnutun that chalk ibis but mug ma.hud an d.Wiaur'ul.brat,hawing the norm eetht rub.auntnotun and shot,wnrkm'cump,policy InWamudae.
1 urn an nnp/uya r6ue if pruvlJlnX rvorken'cumpauodun lu.rurunee�or my emp/oyrrat Se/uw Is the polcy undJub We
hrfbrrrrurinn,
I nwrtice Company Name:
Polwy 4 or Selr-ins. Lic, to: EApirution Date:
lu a Site Address: City/Slutr/2ip:
.\Itacla a copy of the workers' cotnpanlatlaa policy deelarallen p490(rhowlnq the policy mum bar sod expiration dato).
F'.tilura to secure euverage as required under.Section 1.1A u(MCL e. 152 can IeaJ to the imposition of criminal penalties of s
tire up to 11,500A0 and/or one-year impri.mnmenr. as ell as civil penalties in the form of STOP WORK ORDER and a ling of�.y)w M0.00 a Jay tguinst the violator. Ile ads eJ that a copy of this s"Icment may bo furwardeJ to the office or
LtvC,li g�liuns ui the f)1.1 I:tr insurance covara Ymillc4liun.
/du/rrra rri/y r Ju r/re puiru mr nu/rlr.t.,�parjury Jrur r/rr in�u/nrellurr plaYiJtlJ uGYvr it rur•rn sasses
I'h;�;• J
0/jic14 me„n ly. /)n not tvfire in Ibis:urn, rJ br rump/'fed Sy riry ur to,vn•,JJJ,iuf
City nr 1'.nvn: _. _ _ Armit/l.lcenre 4
1.,uior-Awhorily (rirele ode):
1. :iu.trtl ul 11C111h !. Iluilding Uc P.If rtneol I. l ity,T-itvrl Clerk 1. I•:Icetricsl Incpalur i. I'btmhinq Inrptchu
4. ILhc•r
Ciul.t,t I'.fuu'' I'hnne r: