15 SETTLERS WAY - BUILDING INSPECTION (4) k
g� The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7`h ed'taon10
Building Permit Application To Construct, Repair, Renov e Or Demolish a Revised
One-or Two- amily Dwelling Aril 15, 2009
This XctioJ For Official se Only
Building Permit N ber: 'Date pplied::/
Signature: 9 /A/ �Jlr�
Building Commissioner/Inspector of B ngs Date
SEC I N 1: SITE INFORMATION
1.1 Pro Addres : 1.2 Assessors Map& Parcel Numbers
9 SP
L l a Is this an accepted street?ye no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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 yes❑
' / n SECTION/2: PROPERTY OWNERSHIP'
;W4�Owner o Re
N (Print) /V Address for Service:
0/ 7ff--7 -tea s
Sitnature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brie es�riptiop of Prop ed ,1 k2:
7� a // C ,�r� Jc��Yi�c�/
Pl�J i-c
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 9aff- 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (BVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
J' Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ J�7 ov— ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5./1 �Licensed Construction Supervisor(CSL) cvls��7 Y�
Mt__,,a4z iJ License Number Ex ratio
Name ofCSL-Holder
List CSL Ty (see below)
YI ��
ss Type
Description
_
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signatur /,,� M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 e ' ered Ho Impvement ntractor(HIC)
ZO300_S-
HIC C mpan. Name_ r.HIC..Re ' trautName Registration Number ,
xpiratibn Date
Signature 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' AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
'191 I, � v 2 , as Owner of the subject property hereby
authorize Pp��r ,1�I I C In d.tA J . to act on my behalf, in all matters
relativ to work authorized by this building permit application. -
i ature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, ) _ ,armor Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to thebest of my knowledge and
behalf.
e r
Print Name /D/2o A0
Signature or Authorized Agent Date - C/'
(Signed under the pains and penalties of perjury) -
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 and
Construction Supervisor Licensing(CSL)can be found in 780CMR Regulations I I O.R6 and 1 IO.RS,respectively.
2. When substantial work is planned, provide the information below:
Total floors 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 of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
r - Boston,MA 02111
. , www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le gib
Name (Business/Organization/IndividlIual): q,.(— 1'YI P
Address: 1 ri CJOiP 1
City/State/Zip: Phone #: -29 V _ .3�o
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a er with employer 4. ❑ 6 I am a general contractor and I
P Y El New construction
,employees(full and/or part-time).* have hired the sub-contractors
2. \I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp.insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ lam a homeowner doing all work. officers have exercised their I LEI Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information-
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
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 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 hereb=.e, 9
he sins d pen ' s ofperjury t the information provided above is true and correct.
signafore: Date: 0
Phone
Official use only. Do not write in this area, to be completed by city or town ojBcial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6. Other
Contact Person: Phone#: