33 SETTLERS WAY - BUILDING INSPECTION The Cunutaonweaith of Massachusetts Crry OF
` )� Board of Building Regulations and Standards SALEbI
� % Massachusetts State Building Code, 730 CNIR Revised,t/ur?011
1.0" Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Da pplied:
6�to y e y
Building Official(Print N;tme).
Signature- Date
SECTION L•SITE INFORNIATION
LI Property Address: 1.2 Assessors binp& Parcel Numbers
? 600 G1
1.1 a Is this an accepted street?yes no Map Nwnber Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Lot Area(s It Frontage(It)
Zoning District Proposed Use q )
1.5 Building Setbacks
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.411,§54) L7 Flood Zone Information: 1.8 Sewage Disposal System: o
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal systtmL ❑
Check if yes13 :0
r— rn
SECTION2: PROPERTY OWNERSHIP!:
fn m
2.1 Owner of Record: �a � �a 01996 , G
m
�Ine(Print)
r ) �.9L1,P5 City,State,ZIP r0
S q7�- y-4Zf
No. and Strue Telephone L•mail Address cn
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) OL
r
New Construction❑ Existing Building Owner-Occupied g Repairs(s) Alterations) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Bnjoescri jt—ion of Proposed Vorka:
'CN/S� � � Ztil•�
�, o r •
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Rent Labor and Materials)
1. Building S r&0 67r. I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Cityfl'uwn Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Pluntbing $ 2. Other Fees: S
4.mechanical (HVAC) 3 List:
5. Mechanical (Fire S Tohd All Fees:S .
Su ression)
Check No._Check Amount: Cash Amount:
i. 'futal Project Cost: S 3 t-04).er ❑Paid in Full ❑Outstanding Balance Otic:_
4
SECrION5: CONSTRUCTION SERVICES
a�(i astruction Supervisor License(CSL)
' ./Y� CAA Z4 License Number B.epi anon Uate
wne of C. L Holder List CSL'rype(see below)
itz 6-1 4q a S Type Description
No. and Sheet
Sa f�� U UnrRestricted
12 Family
(Buildings u el 35,UU11 Co. ft.)
o� !7� R ResuicteJ 1�.2 F:uni1 Dwelling
Cityll'own,State,ZIP NI Nfasonry
RC Rooling Covering
WS Window and Siding
/�
SF Solid Fuel Burning Appliances
q?p-)yt- aidp a 1 Insulation
'I'de hone Email address U Demolition
cgister,/ed� Ho Improvement Contractor(IIIC) /031JCn�
-4/' lyl1 %-(, jd&A4 ( l-'AP�S;lf`pi/ HIC Registration Number .spiratiun Dute
fll co span Nnn yr HIC Re gi' and Name
i'S r r b e
No. :y+O imJ� I ma. alq��• Email address
Cit rrown,State ZIP 'rm, hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.L.c. 152.1 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 AUTHORIZATIONTO BE COMPLETED WHM
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize U 1f it l /l E l�l ols/(C�.
L9 act on,my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Si ature) Date
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
costa 1 this application is true nd accurate o the best of my knowledge and understanding.
PeYer 90 a.4 7 JrJ�L
Print(Jwy w's or Authorized Agent's Name(Electronic Siguuture) Date
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under I.G.L.c. 1 42A.Other important information on the HIC Program can be found at
wwsv masS.cov'uea Information on the Construction Supervisor License can be found at wwvv.mass.�sov'd.L
�. When substantial work is pkuured,provide the information below:
'rutal fluor area(sq. It.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathroums `lumber of half/baths
Type of heating system Number of decks/porches
Typcof cooling systan Enclosed Open
i. "folnl Project Syunrc Footage"miry be substinited fur"f utnl I'rnjaR Cost"
a
CITY OF SM.EM, NL-�SSACHUSETTS
Bull-DING DEPARTMEINT
120 WASHIINGTON STREET, 3se FLOOR
TEL (978) 745-9595
FAX(9 7 8) 740-9846
KIJ(BERL.EY DRISCOLL
odAYOR THOhviS ST.PIERM
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\L\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Nauru(13usincss Organization'Individ/ual): �P-f I 1 t rr d SWI
Address: l o[ //� r 1 A a p /
City/State/Zip: <:; I M-I ' 1 OO)-21) Phone 8:
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 1 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.�` ,in 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
required.) officer have exercised their
I0.0 Electrical repairs or additions
J.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself.(\o workers' sump. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] i employees. [No workers' 13.❑Other
camp. insurance required.]
•Any applieunt dial checks box AI maxi also fill out the sectiodbdow ihowing their workui cumpensadun policy inrbnnation.
'1 hmK'nw'm.'rx who suhmii this affidavit indicating they are doing all work and then hiro outside contractors most mthmit a new affidavit indicating such
$:nnrxtors thus check this box most anachcd an additiururl short showing dse none of the sub4coiraefors and their workers'comp.policy inrom cation.
l ma an employer that is providing ivorkers'conspeasadon fnsurancejor my employers. /Below/s the policy mid job site
hijorntation.
Insurance Company Name: --...----
Policy 4 or Sclf-ills. Lic. N: 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
tine up to SI.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
or up to 5230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office or
Invrstigadionx ol'the DIA For insurance coverage verification.
l do hereb cerrij i r th at the information provided above is true and correct.
si,na rc Date: �(?.
Phonc d'
Oj)icial use only. Do not ivrite in this area, to be completed by city or town ojpclaf
Ciry or Tuwo:
Issuing Aulhurily(circle one):
1. Board of llcallh 2.Building Department 3.Cityrruwu Clerk 4. Electrical lnspector 5. Plumbing Inspector
6. Other
Contact person:_ _ _ _. __ Phone tt:_--------_—,_--
�I l VF SiU.rm, LY Li�Ssikclq Us ETTS
t BUILD= DEPAR-11LENT
130 WASHCYGTON STUET, 3%0 F.pOR
s T EL (978) 745-9595
FAUX(978) 740-9845
KI3(HF12i.EY DILISCOI.L
,"LAY01 T1-10MAS ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/aL:=LYG CONDIISSIONER
Construction Debris Disposal At'tidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 C&fR section 111.5
Debris, and die provisions of VIOL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting Cram
this work shall be
t 11. S I SOA. disposed of-in a properly licensed waste disposal facility as defined by rNfGL c
The debris will be transported by:
Apr �e/)c
(namn urltauler)
Thi�e``dri
cb �s,wi11 he disposed of in
_[Ill
(name of racdity)
(address ortacility
signanrreufpermitapplicmu