1 PURCHASE ST - BUILDING INSPECTION 1 --- I'lie C'ommuliwealdt of iblassarltusclts
Board of Building Regulations mid Standards CITY t)F
(ten/ s1 ;7 SlusUchusetts Slate Building Cude. 730 C NIR
1 'L"•• Nrrierl ILu 'q//
Building Pcrmil Application 'ro Construct. Repair. Renovate Or DCmulish a
())ue-or Tm•u-family Dtvvflhnq
This Section For 011ieial Use onl
Building Permit Number: Date Applied:
11u11Jing 011icial(Print N;uno) Signature Dat
SECTION 1: SITE INFORIIIA
I.1 Prer. ddress: 1.2 AssessorsHap S Parcel Numbers
y I.la Is this an acre ted street? 'rs no Atop Numher furcal Numbor
I.! Zoning Infortnatlon: 1.4 Property Dimensions-
/.oning District I'ropased tlae Lot Area Isq 11) Fmnmgo(it)
1.1 Building Setbacks(R)
Frunt Yard Side Yards Rear Yard
Required provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40.§54) 1.7 Flood Zone Information: 1.✓f SewaQe Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zona?
Chock iY es❑ Mwieipd❑ On site disposal s)stem ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow ert of Record:
art -S'rL 0114— A—
N;mw(Print) City.Slate,ZIP
/ Pv rril.n J�3i ,1A as S w N, � Co>uC Si• �T
Nu.:utJ Street relephune F.mui1 Address
SECTION]: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner•Occupiij
ed 1,111I Repairs(s) ❑ Alteratlon(s) ❑ Addition ❑
Demolition 13 Accessary Bldg. p. Number of Units Other ❑ .Specily:
Brief Description of Proposed Work':
--T'yt S Uvll�r o
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
I1abor and.\laterialsl y
I. Duilding S I. Building permit Fee: S Indicate how tee is determined:
2. 1:1wrical 5 ❑Standard City Tossn Application Fee
❑Total Pru ecu Cost'(Item 6)x multiplier x
I t. I'lumhing S ?. Other Fees: S
!. \Icch.mical ill\ \('I S List:__
\fcchaocal tFtrc
su.veiii0nl S
n Tidal Project Cost r BOC) Cheri. Vo. _...__('11%?" :\mount: . l',t,h \mm,
O p.uiJ m Full ❑Outstanding Ilal.utcc Due:
St:("I'IO,N S: CONS'I•RUcriON SF.RVIUF.S
S.I C'oastructionSupenisorLicense(C'til,) /OzZY�
icense Nunahar I'�pir,aial p;nc
--- -._. . . _.
• N.nneofCSl. 11oldcr
No. .mcct
IntlS1.
d7 (f5t-e'E1lpl1)pehxhcloal.._I).cscri_pl_io—n
------_--¢-/- _
—
ti 1 him trictc,1Illoddiu s tl to 14,111111 cu. It.)
0/9 76 It Rcalrictcu l.'l'?I.Ilnil Dllcllin
\Loon
('il)i loan,Vale./IP Hlntin Oncrin
µ('
RC Window.u1J Sidin
WS
SF SOW Fuel Iluming Appliances
I Insulution
— Pmail address D Demolition
IvIc hone /11G !' / 9Z L5
5,2 Registered Ilome Improvement Contractor(HIC)
ASS I(ugisl ^ / li pirul' m Date
MW
I111C 'ump tl) N 1nic o IIC Itegistrunt Name
CJ C=am_ '� ':mad aJJrca!
No.and StntiN
Ci lTown,State ZIP 'fele hung
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.y 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atlidavit will result in the denial of the Issuance orthe building permit.
Signed Affidavit Attached? Yes ..........Cl No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER--AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as owner of the subject property,hereby authorize /A
to act(on my behalf,in all matters relative to work authorized by this building permit application.
G i �rLV/F Date
Print Owner's Nurse Mcctrun)e Signumrv)
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 ownwr's or,\uthorwvd,\get •e N,une 1f Icctronic Riguauue)
Nons:
I. .\n Owner who obtains a building permit to do his.her own work,or an owner who hires an o the arbitration b tra i onlmcwr
toot registered in the Hunte Improvement Cuntractur(HIC) Programl.will no have access to then can e r
program or guaranty fund under M-G.L.C. 141_.4. Other important information on the HIC Program can be (iomtJ m
Information on the Construction Supervisor License can be found at,,
2. k%lien substantial work is planned, protide the info)°n ludion nclotra e. linished basement attics.Jocks or porch)
g garage.
rolal floor arca 1s4. R.1 . --- )habitable room count
Cross lit iog area 114, t1 ....... _. . -- Vumher of bedrooms
1 \umber of fireplaces .. - .. \umttct of 11;111 haths
\onlher of hattnwnls - , - - ' Nomber of do As. porches-
, I pc of heating s)stent - I!ncla,eJ ..:)Pen
I I\Pc III COUIII14 i\00II
{, "roial l'ro�e❑ Square FUI,I,ILC Illi\ he HIt,d 1111IeJ tof I llldl P:Ujecl('Pit'
`
CITY OF SM.E.M. NANSSACHUSETTS
• BUILDING DEPARTME2NT
130 WASH IINGTON STREET, 3"FLOOR
TEL (978) 745-9595
FAx(978) 740.9846
Kl\BFRf AY DRISCOLL
MAYOR THOMAS ST.PtxxRB
DIRECTOR OF PUBLIC PROPERTY/BCIIDIING CONLIISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �q ��p 1 , �p� �f�� j[� tease Print Le ibl
Name(BusiixssOrgaan`irattiiorVIndividualY l�\F•r0-' wewiti •`� —' �d
Address: 3 d llj%/e-�
City/State/Zip: -S_!AL1tb0 Phone hl:
Are you an employer?Check the appropriate box: Type of project(required):
i.❑ I am a employer with� 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partnor- listed on the attached sheet.I 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in an capacity. workers' comp.insurance.
Y9. ❑Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers'comp. c. 152, 41(4),and we have no 12:0 Roof repairs
insurance required.]t employees. LNo workers' 13.❑Other, ;T $1i(.A'i16i
comp. insurance required.)
•Any upplicml that ducks bo%#1 most also fill out the section below showing their workew'compenemiun policy.information
'I bxneuwnen who submit this affidavit indicating they ate doing all work and then hire omsidecontmctom mus submit a new amdavit indicating such
:Conlmton that check this box must attached an additional sheet showing the name of the sub�contncton and their'workcn'comp.pulley infomution.
I um an employer that is providing w s'compensadon insurance for my employees. Below Is rhe policy and Job site
informulfon.
Insurance Company?lame: t7Q,�' S
Policy#or Seif--ins. Lic. k: C- G 1 w' Expiration Date: i3
Job Site Address: V)rC1,e-5e_ S� CityiState/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can leadto the imposition of criminal penalties of a
tine up to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be,forwarded to the Office of
Investigatiotu of the DIA for insurance coverage verification.
l do hereb c errijy under the pains and peaulties of perjury drat toe iiefurnrution provided u711_1A__
o a is true and correct.
Sicn;tturt' Datd /_ /1i
Phone#:
OJffcial use only. Do not write in this urea,to be completed by city of town official -
Cityor'Ibwn: PermitR.leense#
Issuing Aulborfty(circle one):
L Board of Health 2.Building Department 3.City/rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other..__
Contact Person: Phone#:
r
CITY OF S.AL.E.Nl, iNLkSSACHUSETTS
BUILDING DEPARTMEINT
• 130 WASHIINGTON STREET, 3iD FLOOR
°
TEL (978) 745-9595
FA.X(978) 740-9846
KlAtgFRT FY RISCOLL
MAYORF, DDR THo.%w ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# 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 MGL c
111, S 150A.
The debris will be transported by: n
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
2
ignature of permit applicant
4
date
JcbruaiGl;x: