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68 PROCTOR ST - BUILDING INSPECTION (3) Z S A6 3S The Commonwealth of Massachusetts E'F fl tr R Board of Building Regulations and Standards WIPE i0N4L SER F Massachusetts State Building Code,780 CMR rpam: yyAAyy Revse`d Mar 2011 Building Permit Application To Construct,Repair,Renovate O�TTeiHALIT A 59 One-or Two-Family Dwelling This Section For Official Use my H> An Build mg Permit Nimtber: k Date App 'ed: -- Bwlding"Official(Pimt Name) - _^' 'Signature Dale "'�SECTIOIVI:SITE INFORMATION 1.1 FlLope Address: SC 1.2 Assessors Map&Parcel Numbers ^ LI a`jIsSthis 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 Requved 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 if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1.,O�wner'of Re 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 ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ FAdclition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: BdepescriptionofPropose Work: SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ \pp p 4© 1. Building PormiI Fee:$ Indicate how fee is determined: 2.Electrical $ 17 Standard City/Town Application Fee _. El Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ :List: 5.Mechanical (Fire $ Supression Totat All Fees:$ Check No: Cheek Amount: Cash Amount: 6.Total Project Cost: $ ❑Paid in Full O Outstanding Balance Due: VYWA SECTION 5: CONSTRUCTION SERVICES ruction"Supgrvisor License(CSL) 5.1 Const M License Number Expiration Date Name of,CSL.Holder <)_ �t; ; pI A aa - C` �' ' List CSL Type(see below) V No.and Street Type Description, _U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry O\� RC Roofing Covering WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) \%\�S (t7-r0 C) y.caA,_,1�\ HIC Registration Number Expiration Date HIC Comp_ any N1 P Registrant Name p No.and StreetR `\ _ Email address City/Town,State,ZIP TelephonArgQ9 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 .......... ❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR 13UYLDING PERMIT' I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. 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: , 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 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. ov.oca Information on the Construction Supervisor License can be found at www.nrass.gov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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" LL t .4 The Commonwealth ofMassachasetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FH,ED WITH THE PERNBTTING AUTHORITY. ` Applicant Information Please Print I&Wbl Name(Busiaess/orgaaizatioarindividaat) `�,� Address: �),at \-�, `� City/State/Zi Phone# Are you an employer?Check the appropriate box. Type of project(required): LE]I am a employer with employees(full aodtorpmt-time).' 7. ❑New construction 2 a sole proprietor or partnership arid have no employees working forme hr $. emodeling any capacity.fNo workers'comp.insurance requved.l 3. I am a homeowner do all work myself ) 9. ❑Demolition ❑ urg ri [No workers'comp.insurance required t 4.❑1 am a homeowner and will be hiring contractor,to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. These sub-contractors;have employees and have workers'comp,insurance.: 13.❑Roofrepairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other I52,§1(4),and we have no employees.[No workers'comp.iosurence requved.] 'Any applicant that checks box#I must also fill our the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the orb-contractors ard state whether or not those entities have employees. If the sub=contractors have employees,they most provide their workers'comp,policy BMW. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. �* Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job 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 coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi n the ins and penalties ofperjury that the information provided above is true and correct. Si store: Phone#: Official use only. Do not write in this area,to be completed by city or town oJliciaL City or Town: Permlt/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M 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"en 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 then three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,constriction or repair work on such dwelling house or,on the grounds or building appurtenant thereto shall not because of such employirtent be deemed to be an employer." MGL chapter 152,I§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 perfomtance 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 sub-contractor(s)name(s),address(es)and phonenumber(s)along with their certificate(s)of insurance. Limited Liability Companies(LI.C)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)and under"Job Site Address"the applicant should write"all locations in (city or town)."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, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia CITY OF SALSA MASSACHLkSE M BERDMDEPAXBFNr 120 WAsrmvGmNSvjw,3RDFioox TkL(978)745.9599__ PAX(978)740-98" 1CIIvI8ERLEYDRISQ7IL MAYOR T STJMM DmEcrCUtoFrusUCMWF 7Y/BUILDmamumopm Construction Debris Disposa/Affidavit (required for all demolition and,renovation work) In accordance with the sixth edition of the State Building Code, 790 CMR, Section 111.5 Debris, and the provisions of..MGL c40, S 54; Building Permit#1 is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: c (name of hauler) The debris will be disposed of in: (name o cility) (address of facility) Signat of applicant Date