28 PURITAN RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALENI
I' Massachusetts State Building Code, 730 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section ForOfficial Use Onl
._. ;
Building Permit Number:;'. Date Ap ie
•
Building Official(Print.N me) ti Signatu7e Oate
SECTION I:SITE INFORMATION
1.1 Pro ert lddress: n 1.2 Assessors Map& Parcel Numbers
L2i U r i��'1 i{
I.la Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Informatio • 1.4 Property Dimensions:
J
1 I Ln TI,+t
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 Zone? Municipal❑ On site disposal system ❑
Check if yesC3
SECTION:; PROP.ERTII'OWNERSftIE'L'
2.1 Ownert of Rc ord:
n 1 lc-(, I Y/o"1'R/` : le^ ��� 0/1-0
Name Print Ct ,State,ZIP
2_6 ��r 1Tgr, 2�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED.WORK°'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition 13_1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work": r
SECTION4: ESTIMATED CONSTRUCTION,COSTS-
Rem Estimated Costs: Official Use Only:.,
Labor and Materials
1. Building S g I i Building Permit Fee:S' Indicpte how fee is determined:
�. Electrical $ ❑Standard.dityf town-Application Fe&.`
❑'rotat.Project Cost"(Item.6)x multiplier x
3. Plumbing S 2. Other Fees: S y_I h /)
1. Mechanical (IIV:\C) s List:,_ yOrl `1 �tJ v
;. Mechanical (Fire S rotal Ml Fees:.S
Sn ILL_ — _
Check No. Check Anwunt: __Cash :\mount:--
rl I'MA Project Cost: 3 $SOD, O-o
f [J Pail in Fall 0 Outstaudim_ISulanee I)ud:
SECTIONS: CONs•rRUCrIONSERVICES
5.1 Constructiun Supervisor License(CSL)
&P r Gly !jL0 _ License Number — Expiration Date
Name of CSL I[older
O
CAS�,` �^ �✓,� List CSL'Type(see below) (/
k
No. and Street type Description
- jsC� m� Q /a2q U UnrestrictedDuildinsup
toin cu. tt.
l / R Rtstrictcd L4t2 F:unil Dwclling
chyrrown,State,ZIP bl Mason
RC Roofin Coverin
\vS window and Sidin 1
SF Solid Fuel [Burning Appliances
1 Insulation
r
hung Email address D Demolition
Registered me Improvement Contractor(HIC) (000 ( '-/ ✓y°S HIC Registration Number Expiration Date
[IIC Calrpny Naa c or (ICItegistrantName /
O BC A 3") GrYt�1 4ty4- eorej f— YNa1 4 40 e G1n1PI 1.0001
o. jre t m� '0/7 2 Q q 7�-`��5.• 4111 - Email address
City/Town,State ZIP 1 Telephone
SECTION 6: WORKERS'COMPENSATION INSUMNCE 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 ..........0 No...........❑
SECTION In: OWNER AUTHORIZATION TO DE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, is 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,
flr" & '�rNnS _ �12-13
Print Owner's or Authu iced:\gent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under M.G.L. c. I42A. Other important information on the HIC Program can be found at
trww.m:us.utro•%oca Information on the Construction Supervisor License can be found at�vww.mass.jot LLldL
2. When substantial work is planned,provide the information below:
'rota) floor area(ml. 11.) —(including garage, finished basement/attics,decks or porch)
tiros; living:uea Oil. ft.l [tabitable room count
NunberoFtiraplaees ----- Number of bedrooms .--- -------_----_---
Numbcr of bathrooms Number of halbbaths -------
I'epeoff1cming;ystcm . _ —_-_._-- Numberufdeeks; porches _.-_. _--.- --------
I\peofatoling :y;tcm
1. "lot d l'n lua 5yu ira Fnnt.i,e"w.ry he ;nb;titnt�-d t •q I' ul l'nqed CoX,
CITY OF 5.lL. ml /G &kcHuspT s
♦j�,. ,. ,r� Ql:[LDLYC DEP.1gTStE`iT
r 120 Cr/.13UNGTON 3rUNT, V FLOOR
TEL (978) 743-9595
f<11t1]LRL 5Y 0RISCOLL FA-X(978) 7•10-93.44
� wo"l 'l1101LUST.PlExA8
DIXECCOR OF PCOUC PROPEATy/BLMnLVG COSL%11SSIO,V ER
Construction Debris Disposal AYRdavit
(required fur all demolition :aid renovation work)
In accordance with the sixth edition of the State Building Coda, 730mmi2 section l l 1.5
Debris, uid the provisions of tLIGL c 40, S Sd;
Building Permit M is issued with the condition that the dcbrrs resulting from
This work shall ba disposed of in a properly licensed waste disposal facility as defined by NIGL c
111, S 1 SOA.
The debris will be transported by:
1VOv'-A f/ Cie CFi top, ., i
(name ut'hauler)
The duhris will be disposed of in :
(unit:of I''ludity)
it ua n(permit•Ipplicaat
�^ / 'hie --- i
i CITY OF S.'1 Y.M LMASISACHUSETTS
• BL'mnmG DEPARTNIENT
' 120 WASHIINGTON STREET,Yza FLOOR
a� TM (978)745 9595.
F.i.It(978) 740.9846•
IC.%IBFRt FY DRISCOLL
MAYOR TliomA ST.PlzRRB:
DIRECTOR OF PUBLIC PROPERTY/BUIIDING COSLIBSSIONEP
Workers' Compensation Insurance Affidavit: Builders/Contra"tors/Electricians/Piumbers
Applicant Information Please print Legibly
Name(OusiocssiOrrtnizatiorvindividual): It— `��^/Y V o f l- 4/�rT/t.-r-T/•s,
Address:l2 f Teal--1f} vL
City/State/zip' .5 91A O/4 2 P Phone n:-_9 7��/S=L/�'? `1
Are you an emplayer2 Check the appropriate box:
ypti of project(requirejadditions
I.❑ I am a employer with 4. ❑ I am a general contractor and l
entployeas(full and/or part time).• have hired tha sub-contractors 6' New constnk ion
2$1 am a sole proprictoror partner listed on the attached sheet t y ❑Remodeling
ship and have nd employecs:,- These sub-contractors have 8. Demolition
working for me In any capacity: workers'comp Insurance. . 9. 0Buitiiing addition
[No worknn comp,insurance, 5. 0 We are a coiporation and iq;
required.) officers have"exerclsed t)ieG I O❑Electrical repairs or
3.❑ 1 am a homeownoi doing all work right of exemption per MGL I I-[I Plumbing repairs or additions -
myselE',(No yvorkcrs"comp. c. 152, i(4) ondwehaverio' 12.0Roofcepairs
'ins urance required.)t i employees:[No workers'*i 13.Q Otters
comp:insunince required)
-Any applicant that chucks box 01 must also fill uut lhu uniae bclow nhowina ihea wmkera•mmpenaotiun twlicy mfominttota' i
1 Nw auwm"who submit this affidavit indicaing thry rat doing all work and ihal him outiido contmcun must submit a new afRJavit inditadna suck,
•Cantrxton that shah this box most attached an a.klitiursl sheet shawies the name of the""Atruton atultha4'workers'comp,puliry iefotrnndoe:..
lam ir,employer that lrprovfding workers'compensot/on lnsu 6ncejor my employeex $e/uw is rhs polliy ngdJob site
lojorinatian n
Insurance Company Name: .
Policy 4 or Self-its.Lic,k: Expiration Data:. '
Job Site Address: City/State/Zip:
Attach a copy:of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of, GL'e. 152 can lead to the imposition ofcnmmal penalties of a
tine up to S 1,500.00 and/or one-year imprisonmen4:as well as civil penalties in the form of a STOP WORK OR DER a fine
of up to 5230.00 a day against the violator. Be advised thata copy of this statement may bo forwarded to the Office of
investigations of llta DIA for insurance'covyrabc yen cahort.,:,
f do hereby cerr4&ur or the and peaulrlea ojpe&4 that the fnf#rmall"provlJed ahoy#,$True and cornet
Data: 2 )
DJrcfal use oss/y. Do not write in t/ris area,robe conrp/eted by clry or townbJjlclaL
City or Town: PermitRJcense 4
Issuing Aulhorily(circle one):
1. Board of Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: ___.._ __ Phone B•