10 SAVOY RD - BUILDING INSPECTION GK 10"7 3
The Commonwealth of Massachusetts RECEIVED yoF
� Board of Building Regulations and StandattlsSPECTIDNAL S P,VIEM
qY! Nlassachusetts State Building Cade, 780 CMR Revised.filar 2011
Building Permit Application To Construct, Repair, Renovatjoj WRoRJ4 aA 4: 34
One-or Two-Fnrnily Dwelling
This Section For Official Use Only
Building Permit Number: D e Applied:
Building Official(Print Name). ; Signature, Date
SECTION1:51116I FORb1A"u"r
t� 1.1 Pro erty Address: 1.2 Assessors blap&Parcel Numbers
I L I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Properly Dimensions:
IZoning District Proposed Use Lot Area(sy It) Frontage(11)
It 1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Require) Provided Reyuired Provided Required Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ p Po y
SECTION2: PROPERTYOWNERSHIPr;
2.1 O vner of Reco d: n
��6A l4tiai
t7 me(Pn t City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ t Specify.
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
Labor and Materials
1. Building S I�3 72' 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Costs(Item 6)x multiplier x
3. Plumbing $ 2� Qther Fees: S /C) t� k
4.Slcchvtical (FIVAC) $ List: r [J
5. Mechanical (Fire $ Total All Fees:S
Suppression)
-� p Check No._Check Amount: Cash Amount:
6. 'rutal Project Cost: $ 7 13 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1/C.on/struction Su/p/c is/orr Icense(UL) ( Cj 102t`�
License Number Expiration Date
Namc ofCSL Holder
ListCSL'fype(see below)
No.;mJ 5'tr�eeyt/ TYPe. _, - Description .
I II ! 4^ n /y�— • �G7�� U Unrestricted(Buildings a to 33,000 cu. It.
L .�J ' 0 t R Restricted I&2 Family Dwelling
Cityfrown,State,"LIP M Maso
RC Roolin Coverin
WS Window
SF SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registt ededflom mproyementContractor(HIIC))Jn �SZjS�� Y 6r
L1 0< le `I/� HIC Registration Number Expiration Date
IIIC Comp; y c or III R ' trant N
Nu.mid et Lg
Email address
City/Town, State ZIP Tele hona
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))..
Workers Compensation Insurance affidavit must be comp! and submitted with this application. Failure to provide
this affidavit will result in the denial of the Wtrance pKe building permit.
Signed Affidavit Attached? Yes ........ No...........13
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUI ING PERmir
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application , ^/
L,5 ./
✓`i`— Ergot e LI � l�5-
Print Owner's Name(Electronic Signature) Dale
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.
lul Z� le Vzq�z_ Pam_. Y �),([i 5---
Print Owner's or Authorized Agent's Name(Electronic Signature) Dale
NOTES:
I. 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 Hone Improvement Contractor(HIC) Program);will no have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
www mass_uoov'oca Information on the Construction Supervisor License can be round at www.nass.��ov/J,z_.Lts
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) 'A (including garage, finished basernenNattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
fype of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted I'or,,Total Project Cost"
COASTAL ROOFING CONTRACT
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GENERAL CONTRACTOR'S AGREEMENT
VWe,the osvoerfst of the pre tho described below,hereby authorize you as contractor to furnish all necazsery materials labor and WOrbmarnilip to holatt con
struct and place die improvements described heren according to the follwving spedficioiuns•terms and conditions on the premises described below.
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�iFAROFF ADDITIONALWORK:
Ld'R{f'tACE SHEATHING WORT ROT 5 PRESENT
S#E(W"ER STOPPER SYSTEM(ACCESSORIES
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ESTSTARTD yATE: -1Z's+5/T EST.COMRDATE 4z -r.-I SECURITYINTIEREST: YES❑ NOD
PRICE s /'f OEPoSlrNITHcRXId 5
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SALES TAX S YVl(i(.i C HONC MPIaIETUN I S y1'S
TOTAL WE 5 RAIMCfMBEFINANODO' S Financed By
'Thkagrermentis s ectm rmanaNWnO"umv mcum Whhln mhty00l days aftuthedate of[his Agreement i(TmwmingxrepNbN w(owal WmdmA Exudooknan
ablafned rvithm30days,this AgreementmaybecanCdledbyeW.paity.
M homeimprovernent<ono-ammxbwbmnbana0mustberegktwed bytlreCNefAtlMnlshatwofshe MastatllrrsetrsBwrtlaf&IiR&g Regulationsantl SLdrMxtls My inquiries
about aontrxmrwwbcanuacwrreWbg ma,aglmatiarlbauldbeditectadm(lhecuvdHome hnproremenl ConlmOm RegislmtionOrN A Ixaron place Aoam 1301,Bohan,W
@1E0.(61N727 M.
TheCrnnacwrshaRobbinxgpayfwlhsbuiMng permitan therpmrmsaMgovemmental Net,Iicemesa inspttommcems krpmpeeaenmonaAmmpWianofthe Wo&
Rthe Onnertlanroobtinfiefaregamg Permits.arm deals unregistered conoactamtheOmlewillbeexClutledfrommegwmnryprovislonsof MG.Is.14M TheOWMrshall
abramarM pay loraBaN.rwceaaa,yapnmvakeaumenls,asseamemsarMtharges
iMCOnoaaweM,hehomeaamalterebYmuoWhagreemadvarue thatmtheevemtheConoanwhnadkyure<axmurgllrisCmrcrxttMContracmr MvwbmR"WCh sbimdon
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NOTICE ThesiprutureofNepaniaaboveapptyanly tolheComranofshepanies malremalivedisWe resdutionmidwed bythe Contractor.The hnmeoemermaylnitiateahemaMe
ditpom reaciu seven xherethk socdanknotfepa2Nty dgned bythepanles
NowwLshalihynpror ladle sigrlmgofdtis Camrecrandtrxummaltpthe Nnerofampyof ft Contract.ThiscantraacorrMwes thepubes'tosalagreemnt.Thlsmotma may
beam¢ndttlwsuppkmen4daNytryavrtGtendwgewderaymM by wmeantl ConVeoar.Absurpitarme alkpropMyo![OASTAIYANDOW58E%IERIOPS.Youagreeto be bwM
byticegeneNl corMitiansofrhereve,Hside
The. ,nabtan ❑Sanykwa rmcies p,wrAearo Omm.
NO ORAL AGREEMENTS ARE ACCEPTED DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES..
Yaw Ma burn,may maeelthk trmuNopatarrytimapdar.mfdni tv:of Ura dflyd knm..a day aft.the a areol Mb uamxtion.See Ne Na&t ace(ant laNan It.
omvltl.d m yw hcevM M an.plwtim of Mk Hgbl
IN WTFNESS WHEREOF•the parties have hereurdaugxN them,woes this Vof
SYfalt '...co. '(atM S ned MFkP
MAKEALLCNECKSPAYABLETOCOASTAL WINDOW58EKTEPoOZ
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The Commonwealth of Massachusetts
' Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Avilficant Information � Please Print Legibly
Name(Business/Organi l J fratioMndividual�):.,, /yn�4'
1
Address: /0 I at, e2
City/Statel �JO/r ��// a Phone#:
V �7 Y - 2g 7 -D 2O�---
yo an employer?Check t 4appropriate box: Type of project(required):
1 ama employer with 4. ❑1 am a general contractor and I 6. ❑New construction
employees(full and/or part-ureic).* have hived the subcontractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7- ❑.Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
require&;] offices have exercised their ]0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. - c.152,§1(4),and we have no 12.❑Roof repairs
imsitral?de required.]t employees.[No workers' 13.❑otter
ra comp.insunce required.] -
•Any appliontthat check&box NI mutt also fill out the section below showing their workers'compensation policy infomuaon.
t Bomcownem who submit this affidavit indicating they am doing all work and then him outside contractors men submit a now affidavit indicating such.
iConvaemm dust cheek this box must attached an additional sheet showing the name orthe sub-convacmm and their workers'comp.policy information.
I am an employer that ispraviding workers'compensa&n insurance for my employees Below is the policy and job site
Information. `
Insurance Company Name:
Policy#or-Self-ins.'Lic.#: !D S�/ ZU �1 SDS1-�77 Expiration Daze. PS/��
Job Site Address: �D SAuo`� �� City/State/Zip: ✓J y i� 0��71]
Attach a eopyo(the workers'compensanon policy declaration page(showing the policy numher and expiration date).
Failure to seem coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify'/under
/{��ie pauu and /en�alltiess oaffecijury th i on provided ahogve c/gtrue/ and co
Signature VVl ".YU ✓"�/? G Date. Y(15
Phone#: f-�
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or iiinplied;oral6f vvnthm." -
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of Me foregoing engaged in a joint cn erpnse,and Including me legal representatives of a decenmemployer,01 ale
receiver or trustee of an individual,partnership,association ar other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction:or repair work on such dwelling house
orronthe grounds or building appurtenant thereto-shall-not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states:that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in•the commonwealth,for any
applicant who tips not prodaced acceptable evidence of couipllauce,with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants. .
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships:(LLP)with no employees other than the
members or partners,are not required-to.carry workers'compensation.insurance.;If;mLLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted:to:tbe Department of Industrial
Accidents for confirmation of insurance coverage. Also be'sure to sign and dete tie-eiildavtt. TA6 affidavit should
be returned to the city or town that the application for the permit or license is b6mg requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law,or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Depamient has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contactyou regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/liceme applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the,city ortown may be provided:to the.
applicant as proof that a valid affidavit is onfile for future permits or licenses. A new affidavit must be filled.out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-26-05
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