26 SETTLERS WAY - BUILDING INSPECTION (2) 1
` 77 '
The Commonwealth of Massacl>,ykETiONAL SERVIC S CfrY OF
�. Board of Building Regulations and Standards SALENI
O Massachusetts State Building Code, 78A 'MA4 _1 A W 2 Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
I One-or Two-Family Divelling
1 ^ Ihis Section For-Official Use y.
Buildin ,g Permit Number Date'Applie
Budding Official(Print Name),. Signature Data
SECTION It S[TE INFORMATION
1.1 Prop ert Add ass: p 1.2 Assessors wrap Bt Parcel Numbers
� � yY2 1 — Parcel Number
1.1a Is this an acceptzd street?yes nu_ Map 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 upply: (M.G.L e.40,§54) 1., Flood Zone Information: 1.8 Sewage D posal System:
Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Public Private❑ Check if es❑
SECTION Z:; PROPERTY OWNERSHIP
2.1 OwrneertofRecord:
I r1-n�r... •X�1_-
Name( ' t) City,State;ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) E3 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief C scription of Pr p sad\ rks: 0.
/L�l-atrCa- �
SECTION4: ESTIMATED CONSTRUCTION COSTS-
Estimated Costs: Ofllelal Use Only>..,
from Labor and ivlaterials
1. Building ; 1. Building Permit Fee.S Indicate how fee is determined:
❑Standard.Citylfown Application Fee
2. Electrical Sb Q�= q'Cotat Project CosP(Item.6)x multiplier x
3. Plumbing S S 2. Other Foes: S
1. Mechanical (IIVAQ S List:
5. Mechanical (Piro S Total All Fees: S_
iuP�ressiun)
Check No. _Check Amount: Cash ;\uwunC'.
r1 l'ntnl Prnject Cost: S �� ,-�� p Paid in Fnil ❑ Outstanding 3alnnca I?ua:
I
_ t
SECTION 5: CONSTRUCTION SERVICES
5,1 Construction Supervisor License(CSL) —
t. License Number ExN; n��L l lol� List CSL Type(see belowNo.and re t Type p
' U I Unrestricted(Buildings u2 to 35,000 cu. 11.
R I Restricted 1&2 Family Dwelling
City/Town,State, ZIP bi blasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I insulation
1'ele hone Email address D Demolition
5.2 Registered Ha a In prove�mQent Contractor HIC)ARV
==,YA.� ' 1,11C ftistratioa Number E. pir; ion Date
1II Company Nam or IIIC egistial t N e
No.an tr 94Tdir �/9�� �8 �Oy �/� Email address
'City/Town, State,ZIP 1'ele hone
SECTION& 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,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 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest u the pains and penalties of perjury that all of the information
contained in this application is true and orate ta'th t of knowledge and understanding.
Priitt�is or Authorized A;ant's N, ,e(El ui.S igttafii-royjG Date
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 Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty Rind under M.G.L. c. I42A. Other important information on the HIC Program can be found at
Information on the Construction Supervisor license can be found at www.mns . nydL,
2. When substantial work is planned,provide the information below:
lToed tlooruea ON. 11.) _(including garage, finished basementlattics,decks or porch)
tiros; living area(sq. d.) I(abitable room count _
Ntnnberoftirrplace;.- ---- Number of bedrooms
Nuinberotbathrooms Numberofhalfbaths - ----
I vpe of hasuing ;ystent " "- - -----.-- Nnmbcr ntdeck.,'porches
I'�peofconlingiy;tcmt _ F:ncluscd
� 4. "I',rt.d I'nq.rt Oyu:ua Fnnt.i�r"m.ty he sub;titnt:,l to "1',rt.d Ih"ujrrt l' nt-- --------— ----
CITYOFS''�• '` .1LE,tit2 ti1v155:1CHU5E'ITS
at:LLOLNG DEPARTUFUNT
t` �� 110 1V.13HLVGTON STREET, J1O Aco,,%
". TtrL(973) 743-9595
FUt(978) 7.10.9345
;<l1t0EQL.EY D(Z(SCO[l.
""UYO+� TFIO1613 ST PIERM
DIxECTOROFpt:ouc PROF ERTY/81:Mn c;CawlISSIO,NEI
Construction Debris Dlspasal Affidavit
(required for all demalition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 C&IR section l l L5
Debris, and tha provisions of MCL, c 40, S 54;
Building Permit t« is issued with the condition that the debris resulting from
this work shall be dispascd of in a properly licensed waste disposal facility as defined by NfGL a
l 11, S 150A.
The debris will be transported by:
ante of h�r�
'l'he debris will bo disposed of in :
(name of facility)
ate.
(idJresa uf't'i,ility)
(aanue nntappti nt
I
tr
CITY OF SME;lri, XWSACHUSETTS
BL'ILOLNG DEP%RTNiENT
120 WASHINGTON STREET,3'D FLOOR
TEL (978)745-9595
PAX(978)740-9846
KIMBERLEY DRISCOt1 Ttiobs►s ST.PtERRB,
MAYOR
DIRECTOR OF i'l:HI.IG PROPERTYf HI:IIZtNG GOJWIISS[ONER
Workers' Compensation Insurance Affidavit:Builders7ContractoiVElectriclans/P[umbern'
A licant Information PI a . Print:Leiribly
. . Name,(BusinassiOrganizaticMlndividual):
Address:
City/Statc/Zip: O Phone -2 = API/�
Are u an emptoyer9 Check the appropriate box: Type of project(required):
1. 1 am a employer with 4. ❑ 1 am a general contractor and} 6. ❑New
con ttructian
employees(full and/or part time)," have hired the sub-contractors
2.❑ 1 sin a sole proprietor or paruter- listed on the attached sheet.t 7. Remodeling
ship and have no employees ' These sub-contractors have 8. C Demolition.
working,for me in any capacity. workers'comp.insurance. 9. C3 Building addition
(No workers'comp:insurance S. We ace a corporation and its.
regtured j officers have exercised their 10.❑Electrieal repairs or additions
3.❑ i am a fiolneowoer doing ail work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.'(No.workers'comp. c. 15Z¢1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp:insurance required.)
-•Any applic m that ducks box Yl must a]wr rill out the section below showing their workers'mmpenaad7oo policy infamution. -
I tomotmroms who submit this iffidavit indicating they ate doing all work slid thin him out"cmttrooams must submit a stew oadavit inflating such
'contractors their clwck this box must anachsd on additional And showing the writ of this sub4offlactort and their wonows,comp.policy infarmntioa:
lam as amployej-ihut Is providing workers'compenradon buurancefor my employeex Below Is the pollly and job slle
information:
insurance Company dame: n, _
Policy H or Self-ins.Lie:M. f 00�- *33 , " Expiration Date: L E
Job Site Address: V / k City/Statd2ipf
Attach*copy of the workers'competuadon Polley laration pogo(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 S 1,500,00 anti/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
Investigutions of the DIA for insurance coverage vcrificalion
I do hereby�cerdf order 16 paln r pat /riot ofperfarythat this lirformadon provided above is true and correct
simiturce Date: G
phone tl•
Ofrcial use only. Do not write in this array to be completed by city of townof claL
City or Town: Pcrmitf1jeense#
Issuing Authority(circle one):
1.Board of IIerilh 2.Building Department 3.City/Town Clark 4.Electrical Inspector 5.Plumbing Inspector
6.Other _
Contact Person: Phone#: