Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
21 PURITAN RD - BUILDING INSPECTION (2)
The Commonwealth of Massachusetts PAICE1 Board of Building Regulations and Standards INSPEGTI AL%hCES Massachusetts State Building Code, 780 CMR ;y Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Dem WNY 28 A 11: 30 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date ECTION 1:SITE INFORMATION 1.1 Pro a Ad •ess: 1.2 Assessors Map& Parcel Numbers tS' 1.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: . Zvniry tli-.hiet � AiotJd llse I,of P.rca(sq R) Frontage(Il) .--_ 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 Zone9 Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner ) -f, . U 5F 11.-91," Nate int)�� 1 City,State,ZIP 1 � h No.and Street Tele� 1:,nail Q d ress SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ElRepairs(s) Alteration(s) ❑ I Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description f Proposed Work l ' SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ I b b O I. Building Permit Fee: $ Indicate how tee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x - 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (FIVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 7 ❑ Paid in Full ❑Outstanding Balance Due: - I SECTION 5: CONSTRUCTION SERVICES 5.1 Consti 6 tion Supervisor License(CSL) 3 4 i ' . ,11lFlt, t n' GS — (' G37Bz 1 (3(%) 1— (Z _ CA)f)M o F_,F: License Number Expiration Date ' Name of CSL Holder 'IF ;I t _ E 1 An 011U List CSL Type(see below) "I 2_ Cyr_;Y Zk l_ 'S fi No.and Street Type Description 1,d O6 /,� �1 U Unrestricted(Buildings u to 35,000 cu.ft.) V ) R Restricted 1&2 Family Dwelling Cityfrown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Buming Appliances 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) �k.-- Luomor— ( ('1'�lZr� © 2-O 1 lL HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 1 Z ��-p�1 T tZ ra L _ ST No.and Street Email address Wuel�,urz J 01 P�vl 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 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 BUILDING PERMIT 1,as Owner of the subject property,Y, hereb 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:OWNEW 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. T 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. 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 ofcooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" �° • CITY OF SzU EM, NLtksSACHUSETI'S I3L'LLD[NG DEPART\W—NT 120 WASNINGTON STREET, Sou FLOOR T EL.(978) 745-9595 F.xe(978) 740-98-46 KI,,IBERLEY DRISCOLL tiLAYOR T HoMAs ST.PiF_Qjm DIRECTOR Of PUBLIC PROPERTY/BCILDr%G COMMISSIONER Workers' Compensation Insurance AfTidavit: Builders/Contractors/Electricians/Plumbere A a ilieant Information {(/ yyyks Please Print Legibly .No nC (nusin<s(Jrganization,'Individu:d): l (SV ' C(, t'\o t--1— AcJdress: � '' J 1 City/State/Zip: , b 6 Uih h p ) a 1 !'hone !t: o 6 6 7 3 Are you an employer'?Check the appropriate box: 'type of prof cc' (required): I 1.(M 1 am a employer with •�• ❑ 1 am a general contractor and 1 6. ❑New consWetion employees(full and/or part-time)." have hired the sub-contractors 2.❑ lain a sole proprietor or partner listed on the attached sheet. : 7. M Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working tin me in any capacity, workers'comp. insurance. 9. ❑ Building addition (No workers'comp. insurance 5. ❑ We are a corporation mid its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 ma a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or udditions myself. (No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t - employees. (No workers' I3.❑Olhcr comp. insurance required.) •A.y upl liaa.n dut vlracks box A I mW l also ell nut the section below shewina their work era'compensation pulicy olAornalion. 'I fomcuwwn who whmit this amrlovit indicating Ihcy arc doing all work and Ihcn hire outside contmcmn mutt snhmil a new a(ndavil indicating such. $lu urcton Out chsvk this boa mtat anachol an addioursad xhml showing he mono of the subeontncWn and their workers'comp,pulicy infuenmion. l ant an employer that Is providing workers'co npeasadan insurance for my employees. l3eluty is the policy and job site iuforruution. Insurance Company Name: , I .L m _f t 1 SUCe-h Q , CO)'v.p G0V"I F- Policy A or Self-ins. Lie.0: /�. 0 _` $l O I L Expiration Date: + 1 1 lub Site Address: tQ I e(1 C 1 tih J, City/State/Zip:_ J ��Yy. /1'I (^ Attach a copy of the workers'wmpensatloo Policy declaration page(showing the policy number and expiration date). .f'ailuru to secure coverage as required under Section 25A ot•NfGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a fine of up ro S2i0.00 a Jay against the violator. De advised that a copy of this statement may he I•urwarded to the Office of Inreitigutions ofthe.DIA for insurance coverage veriticalion. l do hereby c ru r der der puma and peuo(ties of perjury that the infunnuilun provided ubuve is true wed correct. � ,.Ir tore' VW4 - Phone 4: 01liciul use wdy. Do not rvrite in this urea, lobe cutupleted by city ur tmun offfciul City or l'utrn: Permitfi.lcemse 4 Issuing Authority (circle one): 1. Bourd of Health 2. Building Department 3.Cityaimu Clerk a. Electrical Inspector 5. Phlulbing inspector 6. Other Contact Person: Phone ,I: __ _ CITY of S: 1LEN[, ;tiC15S:1CHUSETTS -l/ BL'iLD NG DEPARTMENT 1 1` 120 WASHNGTON STREET, Y4 FLOOR �• TEL (978) 745-9595 Rux(978) 7-10-984S KIJ(BEl2I.6Y D2ISCOLL 1bLAYOa T1{OSNSST.Pmr- a DIRECTOR OF PGBLLC PROP E1tTY/BCtLDLNG COJDUSSIONER Construction Debris Disposal At'tidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section I 11.5 Debris, mid the provisions of k'vIGL c 40, S 54; Building Permit J# 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 rbIGL c l 11, S 150A. "l'he debris will be transported by: y (name of hauler) The debris will be disposed of in ; (narnc of facility) a oa (addmss oftacility) S1511❑(Lftl of t7p'mit dNPtil'dnf Lue 26 i 36" 50 z" W2130L - W243OR WA243 24:DISHW fi ;L ! 1 BEP3L B18R.2FWT 3" Base SB30BUTT-W 2 - Rollout S End Panel ' Trays, ,o �3 o� z 050 A�m CO Manufacturer: Kraftmaid Door: Marquette Wood: MapleCNoa"? +w Finish: Praffn2 SLM3t& o �_ Construction: Standard Top Molding: S6S3 + LCM U w w Ceiling Height: 91" w 0 A CD, 1p C CONTRACTOR SUPPLIED DIMENSIONS; r N n m v m � m A I APPROVE THESE SPECIFICATIONS They have been fully explained to me _ and I have reviewed them. c, Customer Signature 30"—:� All dimensions size designations This is an original design and must Designed: 6/21/2013 given are subject to verification on not be released or copied unless Printed: 3/4/2014 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. Bunn All Drawing#: 1 113" „ 21 " 2" 24„ 24„ 2612" 36" 0 IV - � 2130E W2430R WA2430L M M (,•) om o --T-- n"Irr� M BEP3L4.DISHW, SB30BUTT.WB18R.2FWT EZR36L.WSS SIN 3" Base qrl d Panel 2 - ollout Tr ys 2 3 18" 36" APPROVE THESE SPECIFICATIONS 17" 27„ 9„ They have been fully explained to me and I have reviewed them. All dimensions size designations This is an original design and must Designed: 6/21/2013 given are subject to verification on not be released or copied unless Printed: 3/4/2014 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. Customer Signature Bunn El 2 Drawing#: 1 149" ,, 1 , i, 24" 12"�30"�15"�30"�36" PUTT r=fR3612= 7 1 Inill �ft" WA2430L 1230L W1530R 3030BUTT rF1 I I R WF3.30 o Wall Filler 00 ® o WTEP84> Ref End Panel m ® ® m 36Ft REF-1317 EZR36L.WSS 3_,0-RANGE2! E31 ou Lasy usan 36" 3 331 12' 3 Igo 8 a I APPROVE THES . " 78 8 go They have been fully explained to me All dimensions size designations This is an original design and must Designed: 6/21/2013 and I have reviewed them, given are subject to verification on not be released or copied unless Printed: 3/4/2014 �^ job site and adjustment to fit job applicable fee has been paid or job J\ conditions. order placed. Customer Signature Bunn __Ell Drawing#: 1 440Z/LZI06 +auolsstuauro� 10810 d1N M211190M et 3NONGfo 217f1dd Z8L£9o-SD a spmpull5 pue suolleln6a❑ ouipiing}o paeoE yuawiaeclaci sllasnyaesse� Consumer Affairs& essRegulation Office of Caasumer Affairs&N:fsincss'Regnlatioo HOME IMPROVEMENT CONTRACTOR „ 'r,�, Registration ,103125 Type:i r. Expiration 7/6/2014 Individual PAU R.CUDMORE I i Paul Cudmore 12 Central St. W6burn, MA 01801 Undersecretary