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20 PURITAN RD - BUILDING INSPECTION (2) i � : �� �� \ 1� � � Tha Cuimttumvoalqt of�fass:ui�usetts � Cf('Y UF � �oard of Building Regulations �ud Standuds n I'�� ib(�ssachusetts State Building Code, 130 CY[R SALE�( RavrseJ b&rr 1Ul l Buil�ling Permit Application To Cunstntct, Repair, Renovate Or Damolish a ' Oife-or Tivv-Famrly Uvelling Cfiis Sact'ionFbrdfficial UsaOnf . ` ,. Building Permit Numbev, . � D�)e.APplied:, • � �' uilding 0(flciat(Print Nartie) '.� . Signa D te SECT(ONL•S[TE7NFORitiWTIOIY . ' Ll Pro erty AdJreao: LZ Ae�e�aon b[ap�P�rcel Numben a O �v¢ �T/9.v R. cl l.la (s this an acce tad street?ya i/' nu N�ap Num6er Parcel Number 1.7 Zuning[nformntian: l.4 Property Dfinenaionr. Zaning District Prapased Use Lot Ares(sq 1�) Frantage(R) 1.3 Uuilding Setbacla(R) Front Yurd Side Yarda Reaz Yud Raquired Provided Raquired provided Required Provided ' 1.6 Water Supply:(b(.d.L c.40,§34) !.7 Flaad Zone Infarmutlaas l.S 3awuge D�poaal Sy�temt Pu611c❑ Prlvata�' Zoae: _ Ounida Fload Zane9 Muniefpal p On�ite dlspo�al sy�tem q Cheek if e�O ,,.,, . � ; ,. ., SE�CTION Z;' PROPERTId'OW�IERStIlP!' ': . 2.1 Owner�o Record: c S�a � G �t�V �S J�J �LN'! �/�, . Name(Print) Ciry,Statq 21P � o (�c�ii iTia .,� 97�7i/y3l�6 5C6rsTrev�s�co.�c,ss �/ Yo,nnd Street . . Telephona Email Addreea SECTION J: DESCR[PTION OF PROPOSEII]YORK�'(check oll that npply) ', , New Construction � Esisting Building p Ownet-Occupied Rtpain(�) q ,4lteration(�) ❑ Addition ❑ Demolitfun O Acce�sory Bldg, ❑ YumberafUnit� Other ❑ Specfty: f3rieF Dcscriptian uf Proposed Wark�: e e /Yi e'1"'A L � F{�p�, _ I� iTh A k�o dd Friam� /1 �7GT!/Qe SECT(Oi�iJ: ESTIIL4TEIICONSTRUCTiO�YCOST3 ttem Estim�tad Cu;ts: pfRc(al U�e Onl L�bor ind�(atcrials Y' .. (. BuilJing g 3 poo.o t, I• Buitding PertnitFee:S ` fndicata how fee is dutertnined: �. filcccric:d g � QSI.�ndaid.City/CowrtApplicationFea ' ❑'CutzF Ptoject Cosl�(Item 6).e multiplidr x l. Nlumbin.� S (S ?. OtherFzti: S �j� — I .\(.chania.il (IIV.\�) S p List:. (�� i \Icch.inie.tl (Pir,: i�i + uc:;iiun)- - � d Ibtal :\IlPcas: ) t.L-- — --- — -- -- c'htr.l' No. Clici!c�\utuinrt: ('.c;h :\uiuiint � I'�iral !'rn ��t c 'ii:t -- �--- i ' I ' ' S �`�O o .o D � (] I'.ii�l in Pnll ❑l)nt.;t:m�lim� I I il.inc� I!u,:: - -- �, src•riu�v s: c��vs r�iuc�rw�v sH:iivicN:s i.l Construclian Supervisor Liecn�e(CS[.) -- .._ I.itenst Nwnhur Cxpiratiun D:uu ,l,une uFCSL lloldu (,ist l'SL fypa(sae baluw) �y�a Dasctiptiun NJ. 1i11�I SI[2C1 � Unrcxtrictmd DuilJin �u to 33,U00 tu. tt. R Rcslrictcd 15t2 Fnmil Dwullin City/fuwn,S�uta, ZIP �bf �lwunr RC Ruatin Cuv¢rin \VS WinduwnnJ9idin �R Sulid Fuol Eluming Appliancaf ( Insulatiun fela huna Em�il uddrcae D Ucmolitiun 31 Reglehrcd Hmne fmprovement Contractor(HtC) flfC Ragistrntlun Numbet Expirntiun Uate I IIC Cumpany Nnma ur FtIC Registrnnt Nmne Email addresa No.�nd Stroat Ci ITuwn State 'LIP Tale hone SECTION 6: 1VORKERS'COMPEN9A'f[ON IIYSU[L\NCE AFF(DAVIT(M.G.L. c. 152.� 25C(6)) 1Vorken Compensatian Insurance afHdavit must ha compinted and submitted with this application. Failure to provide thie affidavit will tesult In the denial of the(ssuance af the building'pertnit S iyned Affld�vit Attached7 Yes.........•❑ No...:......,CI SEC'fIOY 7v: OWNER AUTHORIZAT[ON TO DE COdIPLETED WHEN OW VER'9 AGECIT OR CO�TRAC'POR APPLIE3 FOR BUILDAYG PERiV(LT t, ns Owntr af the subjact properry,hereby suthorite to sct on my bahaif, in all matten relative to work authorized by this building parmit 3pplication. � D�ta Print Uwnei f �nma(Elactronic Signawro) SF.CT[ON 7h: U�VNEK� OR AUTHORIZED:\GE�V'f DECL:1ft:1T[OY E3y antaring my nama below, I hereby attest undcr the puina mid penultiee of perjury that all of the infurmatiun contained in thi3 applieatinn i� trua and aeeurata ro the best af my knawladga and undantanding. ,��� �, aG�.� , — n.�« rint U�virr's or Autiwrind:\gtnt'i N,ima(Cltctronit Siguaturo) ,vo�rEs: I. :\n U�vner whu ubnine a buil�ling p�cmit ro�u hivher u�vn wurk,ut;m u�vner�vhu hires:�n unrogistarcd cuntraeror (nut rcgiitarc� in th�Flonro Improvamant ContracNr(HfC) Proyr:un), ��ill nn hava:ucesa tu iha:u�itratiun proyr:un ur guar�nty lund undcr�I•�f.L. c. 112A. O�har importint inFunnstiun un tha HIC Progrem can ba tound at ������ iiri;a �cuv%ara Intorm:itian un the Construetion Suprrvisor I.iccnsm can br Fuund;u u�wv.m,iss.�tuvy�Li � tVhan iubst:u�ti;d �wrk ia pl;inncJ.provi�lo the intormatiun balu,(�' t tinished bascmcnV:utics,dee.l•s ur purch) I'ur,�llloor.irc:�(;��. lt.l _------ _linclu�liny�, g . �iro;; Iivin�;:irr.t(;y. tt.l __ f(.�bicibl�ruomtount _ �lumBarufbcJco�nna __..._--- .----- Nninb�r��flirapl,itc; _------.-- -- �nmh�rnfh.ilE'b.ults _ — ------- vuu�h�r of li.uhm��m.; -- --- . ' _ " — \.illll�)C(u� ��ti�;� �'UI'i�idi . ___" ' "__ � f'.��c ��(h..uiu:{ ;y:lciu - -- - Fuc6rs�l � �Vc�� _ _ . . I��.��� ��I c,n�lin,� :y�.tcni , . . . . ---- � � .. �-.�i il I'n,�.•�.t ���u v,� I'�, I.i,;�,�in.iti I�a ;iih,t�nil,�l I,q� .. l�„r.il I'n��,t�l l'��.�,. $' . . I ,' • � CITY OF S.�I.E.tit PUBI.IC PROPERTY DEp�t�nc�vr V 10Wf7 eveyr a VA�ti I]0 7�writ,�c�}RYT� SK�t�.V�s,�pR sr1T7 Ot f'0 rn..-���f��+� •r.a.r���+o�w H0�14EO1MlER LICE.VSB E.C�.I4PTIO�V Pte.w htat Dw l�v�'vs�i , �0/3 ��c«�. a o P��� T��- R� Sa�L�� Hom�O�voer/1d�tar_ S.e rn � Hom�O�vorr Telephoo� _ 9 7�- 7y</ - 5 ,� o c Praaol Mailta�Ad�+er �S.q... C 1'ti�cuneat axempdoa of"Ftaaeoavnars"w�ataided oo inehid�ow�-0eeupied dweUln�ottwro Unib a tw aad to allowr�ueb 6omeon,ams W m��m �{�,{� for hin who.doa not poua�a lteea�P+'ov{dad that th�o�var acoi sr�uparviaar. DEFIIYI7TON O/HOMEO WNE)! Parwo(�) w6o ow�ns �paeeal otLad as whioA 6d�resida or tnter�d� w rald�, on whlcA tben i� or!i inteaded w be, �aa or nvo (i�mily dweWn� attaehed or detaehed etr�xn+ra ieeeswry to tuch uw u�d/a faim�qyotui,ea A yersoa who carutructa rrtoro chaa on�hom� irt a two year parfod�haU not b�considerad a 6omeownar, yucb �.homaownd'�haU �u6mit to cha 9uildtn�OCllcial,on a forra ycerytab(�W th�Buildin8 �f2fcial, t1�s hdahe be rapanaiblv fo��li iuch worlc perfornsed uader th�Huildtn� Pamit T��°"d�� ,��omO051'"4"v+uma raponubiliry for eompliuie� with eh�Stau Buildin�Cod�ard o�ha �pplteabl�bylaav� uid rc�ulstfans Ths undmi�ed "homaownd'cerdRa that hd�ht undmtand� th�Ciry of S�Iem Buildin� Oryar4nent minimura inspeerion proeedura �nd requirrmrntr and rh�t hd�hs .vill comply with �aid procedura utd raquiremrnt� NaStEO WYER.q S(GNA T(,'RB .WPROV.�L OF 9U/LD .NG bYSPECTOR See o�her �iJa far st�te cai� n e.� I .l�)'Ii' ` 1 _� . ; C(TYOFS.ILE,til, LbL155�tiCHUSE?T5 �;,• � `� �� , Ot,��crc D�p.iari�.vr ,�����,+ I 0l'V43HctGTONSTI2E } r ,\,` ,� ET, �°Ft.QOR '_~.' `'"' I�L (979) 1�3-7593 t<1�c0E2LEY D2rSCOLL F+-'�(')l3) 7•IU-93-I.S ,�,L�YO;t �[}t01G1i ST.P1E3ri8 DCLECTOR UF?CO(1C pRapggTy�BC��yC C01L1(!55lO,V ER Corrytruction Debrl9 Dlspasal At�Iduvit � (rcyuirEJ toc aU �tcmalilion :uid n;ttuvatiart wark) !n accuRlsnco with di�r sixdi eJitiurt aFthe 5tata Buitding Cada� 730 C�bfR section l t L 3 Ocbri�, vid qie proviviuns ut'�b(GL c d0, 9 id; �uil�ing prrmic,� iy issued tiv�th the cartJttlon that tha dcbds resultfng Prem lhiy tivu�!c shal! be dispusc�l of in u properiy licensad �veytd Jtspasal fauility a,g doHncd by �LfCL u ' ilI, 5ISQA. 1'hu cichcis �vill ba trinsportcd by; �GbTTG 57—�-e v�i„5 (uamc uChaulur) '!'he Jchri:l wiN ba dispo.,rJ ot'in : .L�/caz�li S/rJ� C�g2Ti� ------ (nnmu ut I�cdity) I _�u'��'^/�S�o� � � S�.<�,� (i�ldres.� ur'r:�.lhir) . 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