4 SHILLABER ST - BUILDING INSPECTION One or Two-Family Dwellink
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachuseas State Building Code, 780 CMR 7°'Edition
Application to construct,alter,renovate pair r demolish
This'Seetiun Fo1 ()TfiE4 1.I36�
Building Penn it Number: D to of a
Signature.
Building Commissioner/Local Ins ec or Date
SG1ON 1+ SITE I VFORMATTON
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
l.la Is this an accepted street? Yes ❑ 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(feet)
Front Yard Side Yard 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?
Check if yes ❑ Municipal❑ On site disposal system ❑
1.9 ZBA Special Permit 1.10 Old &Historic Commission 1.11 Conservation Commission
Date tiled N/A ❑ Date filed N/A❑ Number 40- N/A❑
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2.1 Owner of Record:
MAVO 11414e4~ Lf/, J.y/Lcaa�st. J T.
Name(Print) Address for Service
Signature of Owner
Telephone
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repans(s) Alteration(s) ❑ Addrion R❑ ^
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Description of Proposed Work: 7ZE7�ceyF Ex�tn.ra /to?TEyj s.rly
�viLb Ne=w ,vF _.
SFLITOIV ESTINSATtEI1 CONS1ZUGd'[b1VCOSTS $jIJpIIYC4P7I11Y i1 FF) F
Item Estimated Costs "
(labor and materials) This Section For Official Use Only
1. Building $ 7f� oa Building: $10/$1000
2. Electrical $ Building+Plumbing: $12/$1000 Building+Electrical:$l3/$1000
3.Plumbing $ Building+Electrical+Plumbing combined:$15/$1000
4. Mechanical (HVAC) $ Total project cost(labor and materials)$
$
Fee multiplier from above$ /$1000
5. Fire Suppression
6. Total Project Cost $ Permit Fee$ Receipt Number
SECTIDN,S:, C,ONfiTRUCTfON;SERVICE S
5.1 Construction Supervisor License(CSL)
/FDA �IXEF License /03733 Expiration Date
Name of CSL T Description
JO UrgavN fT /N��'tlCEflR77b U Unrestricted(up to 35,000 Cu.Ft.) n
Address R Restricted 1&2 Family Dwelling
t M Ivtasour y Onl
Signature RC Residential Roofing Coveriug
7.fI_6 31 — ASS $ WS Residential Window and Siding
Telephone SF Residential Solid Fuel Burning Appliance
D Resideotial Demolition
5.2 Home Improvement Contractor Registration (HIC)
Registration 6j/ VAp Expiration Date 'o7.F—/
HIC Company Name or HIC Registrant Name
3c. "rew t Jr
Address -
/ r w
t a re
7P 63t
Telephone
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Lett > � �tnrz�r� IEr o� 3 s'
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Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affidavit ma result in the denial of a building permit.
Signed affidavit attached? Yes No ❑
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t: ��15 �i �-A� F���TR% 3 � t y" 3'D l•J� � .1��.,�._ �L y �., ��p, 5� E' {p J Y
I MAVKH /llptCE79� , as Owner of the subject property, hereby authorize
—rtt2 t stC�.v 1c6W.02&-,u to act on my behalf in all matters relevant to work
authorized by this building permit application.
Signature of Owner Date
k u� �''2 F '� ir�� F �a � a F 3 F ^F - � -p x A 'f. ° 1�• � u { -
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I as Owner or Authorized Agent,hereby declare that
the state fo foregoing application are true and d accurate, to the best of my knowledge and belief.
1.2
Signature of Owner or Authorized.Agent Date '
(Signed under the pains and penalties of perjury)
NOTES
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 110.R6 and 1 IO.RS.
When substantial work is planned,provide the following information:
Total floors area(Sq. FL) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Number enclosed of decks/porches
Habitable room count Number open of decks/porches
Number of bedrooms Number of fireplaces
Number of bathrooms Type of heating system
Number of half/baths Type of cooling system
The Commonwealth of Massachusetts
! Department of Industrial Accidents
Office of Investigations
600 Washington Street
l Boston, AfA 02111
www-m
Workers' Compensation Insurance Affidav is Builders/Contractors/Electricians/Plumbers
Applicant Information
�� Please Print Le ibl '*Name(Businessiorganization/Individual): 1Tz7_iC LSl0kV
Address: 3G c fFzv/�// `/7—
City/State/Zip: /WWdLtwi w p A10* �iIfV Phone#:
Are y an employer?Check the appropriate box:
1• I am a employer with e 4. 0 1 am a general contractorFanui,,redYPe of project(required :
)
employees(full and/or part-time).* have hired the subcontraN�a+�c�nstruction
2. [am a sole propr etor or partner- fisted on the attached sheRemodeling
ship and have no employees These sub-contractors ha
working for me in any capacity. employees and have work ❑Demolition
[No workers'comp.insurance comp. insurance.t ❑Building additionrequired.] 5. (] We are a corporation and .0 Electrical repairs or additions3. I am a homeowner doing all work officers have exercised thmyself.[No workers'comp. right of exemption per MQ Plumbing repairs or additionsinsurance required.]t c. 152, §1(4),and we haveQ Roof repairsemployees. [No workers' 0 Other
comp. insurance required.]
*My 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 hire outside contractors must submit a new affidavit indicating such.
eContractors that check this box must attached an additional sheets the name of the sub-contractors and state whether or not those entries have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number,
f am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins,Lic. #:
Expiration Date:
Job Site Address:__ L/ � ///,y,� C JT
City/State/Zip:CfigLEitc
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 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.
r�4_ -rd G G
y cerr fy under the pains and penalties of perJury that the information provided above is true and correct
i ratu � --� � �>
Date O
Phone#: d/-- r/ 7 SSA
[Contact
al use only. Do not write in Geis area,to be completed by city or town official
r Town:
Permit/License#
g Authority(circle one):
I. rd of Health 2. Quilding Department 3.Chy/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector
er
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 implied,oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a.joint enterprise,and including the legal representatives of a deceased employer,or thy.
receiver or trustee of an individual, partnership,association or 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
or on the 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 has not produced acceptable evidence of compliance 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-contractor(s)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 an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being 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 Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the penniUlicense number which witl be used as a reference number. In addition,an applicant
that must submit multiple permit1 icense 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 or town may be provided to the
applicant as proof that a valid affidavit is on file 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 bur 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 4-24-07 www.mass.gov/dia