29 SETTLERS WAY - BUILDING INSPECTION (2) I The Commonwealth of Massachusetts
(l ° Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7`" edition
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised
One- or Two-Family Dwelling Aril 15, 2009
This Se n For Official Use Only
Building Permit mbee�r:,,, Date Applied:
Signature:
Building Commissio /Inspector of B t s Date
SECTI 1: SiTE INFORMATION
1.1 Prou er Ad��s: 1 1.2 Assessors Map&Parcel Numbers
Cl
e
L la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
ti 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[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'of Recor+cy�l
-_ vSAo2 Uzoil . v7q SP�711"dS
Name Print) Address for Service:
` `
e Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Bri Descrt*t�tion of Proposet�,Work':
t'D/t�PP C�XIS!/K9 Clilyr i �j o/ stlt9s
62 ltil i S .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 9 yb 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical
❑Standard City/Town Application Fee
$
❑Total Project Costa (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ j �f JO �TjT 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES v
5.1 Licensed Construction Supervisor(CSL)d
PP-PT 14 1"-0-4,1 J Licen e Number Expiration Date
Name of L-Hol er
List CSL Type(see below)
A essType Description
U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted l&2 Family Dwellingttur -
Slg/n�aee p M Masonry Only
`7 T/ — >y y3 a t2- RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 e P�Ho �pr ement Co tractor(HIC)
H mp Name qr'HIC Reg t ant Na Registration Number
(y /A9 A ress y� p /,I7' t�
/70 �'7 '�3p E,-fnrati,A Date -
'gnature 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'S AGENT OR CONTRACTOR A PLIES FOR BUILDING PERMIT
2I, as Owner of the subject property hereby
au orrze to act on my behalf, in all matters
re la ' e to work authorized by this�buildinng permit application.
�(
l\ Si re of Owner Date
hSECTION 7bRlOR AUTHORIZED AGENT DECLARATION 1 P f 1 C1 21111 J _ I ,.arr9=er or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behal .
I
Print Name
F1101io
Signature r uthorized Agent Date
(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 780 CMR Regulations 1 f O.R6 and 11 O.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 oflndustrialAccidents
m —( Office of Investigations
600 Washington Street
r� Boston,MA 02111
r
' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I, Please Print Legibly
VI
Name.(Business/Organization/Individual): P'l�
Address: r 1 d Gq F
City/State/Zip: Phone #: _ j
TZ
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).*
proprietor or partner- have hired the sub-contractors
2I am a sole propr listed on the attached sheet 7. ❑ Remodeling
ship and have employees These sub-contractors have g. ❑Demolition
working for mein any capacity. employees and have workers' 9 ❑ Building addition
o workers' com insurance comp.insurance.#
� P� 10.❑ Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ I required-]
a homeowner doing all work. officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per 12.❑ Roof repairs
c. 152, §1(4), and we haveve n no
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required]
*Any applicant that checks box#1 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.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors 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 thepolicy and job site
informatiom
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 numher and expiration date).
Failure to secure coverage as required under Section 25A of MGL a 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 c u der thee a�inss and rraI 'es ofpe ry that the information provided above is true and correct.
oianature �'</ % �T "�C Date
Phone# O — / < l — t Z `l�co
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. Cityffown Clerk 4.Electrical Inspector S.Plumbing Inspector.
6. Other
Contact Person: Phone#: