12 RAWLINS ST - BUILDING INSPECTION (3) �` 1 �Z 5��� � o
� Z� -7 - l � � �o� �- 2--
� � Che Commomvealth of btassachusetts
, E3o�rd of Duilding Regulations 1nd Standards CfI Y OF
��i I Ntussachuse[ts State Building Code, 730 CbIR SALE[vl,
����� ReviseJ.tlm•_011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-nr T�vo-Fnnrily Dwe!li�rg
This Section For Official Use Only _
13uilding Permit Numlier. Date Appliedr
ti G ` p
6uilding Ofticial(Print N�une).. � � '-�Si aturq^����. . . � � Dn[e
SECTION t:SITE INFORiV1ATIOIV
L t Property Address: L2 Assessors binp 3c Parcel Numbers
��a R�..,�,hs S+
I.la Is this nn accepted street?yes ✓ no ���P����»ber I'arcel Number
I.1 'Lm�ing information: t.4 Property Dimensians:
"Luning District Proposed Use Lul Ama(sy tt) Prontage(it)
I.5 6uilding Setbncks(ft)
� Pront Yard Side Yartls 2ear Yard
Reyvired Provided Reyuircd Provided Required Provided
1.6�Vater Supply:(M.G.L c.40,§54) l.7 Flaod Zone Informntion: L8 Sewnge Disposel System:
Pi�blic 6� Private❑ Z°°e: _ Outside Pluod Zont? M�micipal O On site Jisposal system ❑
Check ifyesO
SECTION2: PROPERTYO�VNERSHIP"
2.l O�vner of Recard: �y.,
�!`.�.51c1e �.1,Icl�..� t' Q.cr�.�c�e(..a !"�� �Y �'� �i�¢r. }✓�fl U\yzu
���hine(Pnnt) . CitY,Slate,ZIP
�� O� �'xx '1"bC— ul8 �l�-t� llcn�
�u.;md Strcet Telephone Email Addresg
SECTION 3: DESCRIPTION OF PROPOSED�VORK2(check nll that npply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition �
Demolition ❑ AccessoryBldg.❑ NumberofUnits Other ❑ Specity:
�rieFDescription of Proposed \Vurk':
✓�<v..� "�.�✓�\c,c ,�c�r� 2�W
SECTION a: ESTI�HATED CONSTRUCTION COSTS
� �n Estimated Costs: Official Use Only
L�bur and i�laterials) �
� �i�������� � 1. E3uildinn��Permi[Fee:$ Indicate how fee is determined:
�. Elactrical g ❑Stlndard Ci[y/Town Application Fee�
- ❑Total Project Cost�(Item 6)s multiplier s
3. Plumbing S 2. Other Fees: $
d. �Icch�nical (HVAC) S LisC
5. h(zeh;mical (Pire � .
Su ressiun) �I'otal All Fees:3
�Check No. Check r\mounC Cash r\mount:
!. Tutal Projec[Cust S a,SU (b V ❑ p;�id in Fuli ❑Outsmnding[3alance Due:
SECTION 5: CONSTRUCCION SF.RVICES- .
S.1 Construction Supervisor Liccnse(CSL) ��a V2� �^ �a-��
��45 C �`'"S , V License Number E.epiration Date
Nmna ofCSL Flolder �
List CSL"fype(see beluw)
� ` ��'iev�.J�c� ✓'��{ . . . . .
No. :md Sueet . Type �-� Descriplion , �
�C45o�� �\ la p�� (>p U Unreslricted Uuildin�su to35,000cu. R.)
R Restricted 1&2 F:unil Dwellin
Ciryllb�m,State,"LIP M Mason
RC Roolin Coverin
WS Window and Sidino
_ SF Solid Fuel�uming Appliunces
Qt l}j glS�i-1�L f Insulation �
Tolc hone � Cinail address D Demolition
5.2 R^e�gistered flome Improvement Contrnctor(11IC)
rJ°i�15�� ��•l��"'a g �'""'"�e �� � HIC Registr�tion Number Grpiration Uale
I�I IC Com ;ury Name ur HIC Registmnt i ame � -
�U- �lY� �'�'
No. and Strqet Gmail address
Sa,\e.-.., r�W ��q^tu qt'!� �l-1\ 1"iW
Cit /Town, State,Z[P 'Pele hone
SECTION 6: �VORKERS'COM1IPENSATION INSURAIVCE AFFIDAVIT(M.G.L.c. 152.§ 25C(�).;
Workers Compensation Insurance affidavit must be completed and submilted with this application. Failure to provide
this aftidavit will result in Ihe denial of the Is'suance of the building permit.
Signed Aftidavit Attached? Yes .......... � No...........❑
SECTION 7a:AWNER AUTHO.RIZr�T[ON:TO BE COMPLETED WNEN: • .
01VNER'S AGENT OR CONTRACTOR APPLIES FOR DUILDING PERlNIT`
1, as Owner of the subject property,hereby authorize ��u-�c� S � (��-- , � `�
�t9 nct on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nama(Lleclronic Signature) Dale
SECT(ON 7b:OWYER�OR AUTHORIZED AGENT DECL.ARATIOIY
6y enterin�my mm�e below, I hereby attest under the pains and penalties of perjury that all of the informatiun
contained in this a ication is true nnd urat o the best oF my knowledge and understanding.
� Print Own� '� AuthnrizeJ AgenCs Nnme(Gle nic Sianalure) Date
NOTES:
1. a\n Owner who obtains a building permit ro do his/her own work,or an owner who hires nn unregisteteJ contractor
(not rzgistered in Q�e Home Improvement Contractor(HIC) Progmm),will i�o[have access to the arbitntion
. program or guaranty Fund under�bLG.L.c. 14?A.Other important information on the HIC Program can be found�t
' �cww.mas,.eov/oca Information on the Constructiun Supervisor License can be found at w���r.m:�,,.��o�:!J�Ls
� �. \Vhen substantial wurk is planned, provide the inf'onnation below:
Tutal floor nrea(sq. R.) (including garage, finished basement/at[ics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of tireplaces Number of bedraoms
Number of bathroums Nwuber uf half/baths
"Cype uF heating system �umber of dzcks/porches
'fype of cooling system Gnclosed Open
J. "Potal Project Syu:ve Footage"may be substituted For`"Cot:il Project CosP'
1
, . /F/°� ' l�ll 1 QC" Ji�� .r.i�j� LY�L�JS:iC�{UrSL.'TTS
�' E3L'ILOG�IG DEP.ift'i�l&�iT
a4}_�t�?i. 1�0\Y�.�JHINGTON$TREET, Y'FY.00R � .
'�� T�L (978y 745'-9595
� F.t��c(973) 740-98�i6
KiJBF1tI.EY DRISC011. TriObNS StP1E.aR8
1�ic1YOA
DIAECTOR OF P1:0[:IC PROPER'[Y/HI:II.DL`3G CO3L\IIJSIO:iER
. . ... . . . ....__. . __._
Workers' Compensatian insur�nce Aftidavir Duildcrs/Contractor.vlElectricians/Plumhers
4�iplfcant In(orm�tton Plcase Print Lepibtv
VittllCl�win�yyOr�aniratiorvindividuai): �.7«�S�'G/tc �J\�GM _ � ,C�^'�ect ��.��.
/�I�IICC�JS: � � U - \S�� �a-�
City/StatdZip: � c�-e� � �- Phone 1t: Q,'1 � '�`1 � 1�7 UC�
,�re you nn employer?Check the uppropdate boY: 'fype uPpmject(requ(red):
I.0 I�m a em lo er with '�• � ��v B�n��l cantrutot and 1
P Y 6. �luw eonytnution
amployea(full and/or paK-tima).• hays hired�he aubcontncton
Z.O 1 im a sola proprictor or ponner lis�ed on�ha attached ahact t �. ❑�emadeling
,hip:u�d hava no amployeea These subconaacton havo Y. � Demolition
wurk(ng fur ma in any capaciry. worken'eomp.inauranca. 9, �DuilJing additian
(No workcra'comp.inwranca 5.'0 We are a corpomN6n ond iq
nyuircJ.J
o(Reen hnve sxeroised thatl �0.[]61deMicql rcpain ot additiana
- 1.0 I om a homcuwner doing all woh cight of exemptiun per MGL I 1.[]Plumbing rcpuin or additiona
myxif.(No workcn'cump. e. I52.�1(4T.nnd we hnve no 12.0 Roof ecpein
� insurance reyuircd.j t amployaea.[N4�vartcera' IJ.Q Olhev
cumg in.wrance mquimd.j.
•Any appllc:ua ihat ehwk�has Yl must alw��II uu1�h�ucliva bnlow ihowiny�ha4 waken'rnmpenwiuq polt�y infiirtnalloti
�I L�nauWncn who�u6mi1�ht�adidnvil indiainy ihry�n doiny ull�wrk ond Ihm AIN uV4idemntmctan mwl�u6mi1 a�mw aOlJavil indiaina mck
=Camra.ico ihol ch«k iht�Dux m�at miuhod an mWitluro{�h�el ehuwinp iho mm�e of tA6 aub-coefncton and iha4 wurkan'mmp.pullq infamaNan.
!mx un eurpluyer rhat lr provldGrg�vorken'romprnacNon G�turancs jo�my empluyerx Beluw fi�hi paltcy and Job s!b
iujonnmlam
. InwranceCumpanyVame: � ��M '�'�J�4 � �Svv � S
P�iliey B ur Self-iiu.Lie. tl: � �1 < Expimtion Dute: 3— 1 l— L"I �
lubSitaA��lresy: � �- �v� � 5 S} CirylStatr/Zip: �4�-�-�-� ✓'^ W �15�[)
,1tt�ch a copy uf lhe�rorken'compematfou pollry declantloo paK�(nhowing Iha polley num6or and axpfntlon date). �
Pailuro to sceun:covaruge yv«quireJ undcr Sccdon 1JAuPMGL c. 132 can lead ro tha impoaitian ofcriminnl penaltias of a
line up m SI,500.00 unJlur one•yaar imprisonmenq a�walf ax civil penaltiea in thn focm ul'a STOP WORK ORDEA anJ n lina
nf up ro 52.i0.00�Juy ayainsi iha violamt ❑e aJvixcd ihat a capy uf�hixstahmcnt�nay txt furwardud to tha 011icu of
6rvcsligwimtv uf tlio DIA for insurence cnverage vcrilicalioa . .
/du/rrrrby cnrtjy rmJer di�UI//J�ff/1'iI�llll JI/I�dt°jprrj�ry t6ul!/re i�junnulla�praviJrJ ubuve is trui mrJ cunreG -
' `�J �--�-� .�L// �_3�- t�
Si�m�unrC � / Dar �
1'h,inc,1• `t�� ��1 \ / `� �aU
UJJicr�!use o��fy. Oa nof ivrite in dri.r urru�!o bt cuwplelyd by city u�lown n/JTr1uL
i
�Citynr�l'�i�vn: _.__ Pcrmtt/i.lccma.�
� II.�suing.\Wlmrily(cirdounej: � -- -- ..
i. l7uurJ uf Ileallh 1. 1luildlnq Ucpartment .1.Cilyi fo+vn Clerk 1. Electrle�l Lupector i. Plumbfng In.speeror
I G. Odicr ..-- ----- , .
� Cunt��ct Pccsnn: .__. _ . _._ _._ PAonc B• I .
i
�
,: '`'" CITl' OF S.�LE1�t, itiL-�SSACHLTSETTS
• �• BL:ILDL\G DEP1R'I'�IEtiT
� � �� 120\YIASHL�IGTON $TREET, 311D�OOR
� ,�`�°'`� "I'Ei. (978) 7�t5-9595
F.1x(978) 7-1Q9846
��tgFRT RY DRISCOI.L
,tii.�YOR THo�L►S ST.PL£RAS
DIRECTOR OF PliHLIC PROPER'IY�9L'II.[)4\'G COSL�(I5SIO�iER
Construction l�ebris Disposal �t'�davit
(required for ali demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 CMR section t 11.5
Debris, and the provisions oF N1GL c 40, S 54;
Suilding Permit # is issued with the condition that the debris resulting from
this work shal] be disposed of in a properly licensed waste disposal facility as defincd by MGL c
l 11, S I SOA.
'fhe debris wilt be transported by:
y --�.t.�� Yu�,,�
(nama o 'hauler)
"I'he debris will be disposed of in :
�U� \ �vc..i�
�-----�--�� (name of facility)-. �—�_
_��� M �
(�ddress of Facility)
i
signature of pecmit applicant
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