24 SURREY RD - BUILDING INSPECTION I'he C'unununsve;thh of�lassachusclts
Iludrd of Building Regulations ;tnd SI:mdards CI I1' of
5� t?a,;..� �IassaehuseRs SL1tC Building Code. 7SO C'AIR SALEXI
Building Permit Application To Construct. Repair, Renovate Or Demolish a RVIArd Itar`I)/f
Ow-ur Tov 4limrlr Utre//in,V
this Section For Otliciil U c Old
!luilJing Permit Number: Date Applied:
Uudding Otllclal(Print N,uno
Signature Will
SECTION 1: SITE INFORAIATIO4
Property Address: 1.2 Assessors,flap di Parcel Numbers
I.la Is this an acce led$(feet? •es c/no flap Nuotbur Purcel Number
I.J Zoning Informations 1.4 Property Dimensions$
Zoning D— is Viet — I'nlpaxJ(Jw Lot Arco(sV II)1.1 Building Setbaeks(R) Fntntuye(11)
F'roat Yard � Side Yards
Required Provided Rear Yard
Reyuircd Provided Required 1'tvvideJ
1.6 Woler Supply:IM.G.1.e.Jo. 5 34) 1.7 Flood Zone Informations
Polblle O Privme❑
Zone: _ Outside Flood Zone? I.II Sewage Disposal System:
Check If a0 Munidpd❑ On sib disposal$$stem ❑
SECTION 2: P PERTV O N HIPS
2.1 wnerrofR $
Man (Print) Cily.Stotu.'...
No.a 11 Street
' relrpbune Email AJdross
SECTION is DESCRIPTION OF PROPOSED WORK'(check ell that apply)
New Construction O E. isling Building O Osvner•Oceupied (3 Repairs(s) ❑ Alteration—($) ❑ Addition ❑
Dentolition ❑ accessory Bldg. ❑ Number of Units
BriefDescripti OrprrooQosed Work': Other ❑ .Specify:
SECTION 4: ESTLILATED CONSTRUCTION COSTS
Item Estinmted Costs:
It abur and Materials) Official Use Only
I. OuilJing S I. Building permit Fee: S Indicate how lac is determined:
'. Hwrical S (3 Standard CiryTosvp Application Fee
t I'lunlhinq S O Total Project Cosh(hem 6)r multiplier
:. Other Fees: S_ 4\
J. "llanic.J III\ \t'f S List:._
i Cu.Ve)flont S
coral \11 Fevi: S_ _
n Tntal Project Cud: i _ C'hv�h Vu. _. __C llv A .Nnl0mnc l',uh \lu.lunc
❑ P.IiJ in Full Cl Outstanding 11.11.utce Due:
r �
St:('I'loN S: ( ONSI'RU('TION SF.RYI('FS
S.I CunstruCti ItSupen ur Licenit ICSI.I rr nnulnn Uow
I Iczn,z Numhcr I
on/ _
N.uncofl' IlolJcr /) hell'Si. l\PeVeehcluwl.._,_—._ _-- .._
.Y� i•O 'I•)P4 I)ciUipliun
No. .nIJ Slreul � ,( (I UnreatncleJ 111wtJin a li to 15,11110 al. Il.l
—I� �✓/�.__, _—_ it µe,Iri.IzJ TOf.unil Dllzllin
1. .\I \hlilul
l'ip(I',re n,S1.11../IP µl• Karlin l'rrrcrin
WS N'indow,uldsidin
- SF Solid Fuel lhlrniny,\Ppliances
Insulation ,..
/ ' —�t Pmail aJJnai D Dzmolilian
-I'cic bona
$1 Registered llume Ingsruventeat Contractor(HIC) III- I(egiau;uiun Number li,Pin 111,11 Wig
I Ill•l'onlpuo) NAlne or I Ill' Regis Namo Emuil uJJraas
No.and Street
rcic hung
Ci !Town,Slate ZIP
SECTION 6s WORKER?'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 1�3. 23C(6)
Warken 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 .........• O
No...........O
SECTION 7as OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my yhal4n a iatte relative to work autho rriz by this building ermit applic tlon
Data
Print U,,et s Nwna(Elcvtrul is Signuturo)
SECTION 7bt OWNER' OR AUTIIORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in thi application is true and accurate to the best of my knowledge and understanding.
�n A f Ci� Data
Print Owne iur:\uthorircJ,\6a lit'i Nanw lhlcctnmic Signaluru)
No rest
.nutOregist red iobhetHu ne hnproPe uentlCuntr aturlHlCl Program).n illdur(have aaess tolthe arbirtrationllractur
program or guarml) orn
Infomwuun on the Cumtr A..o other Supen iar t elnselcan be found at
ation on the C Program c>nrbelrlhund at
\\hen subslamial rwrk is planneJ, prutiJt the intunnatiun below:
I including garage, finished basement attics.Jocks or Purclu
rotal Ilour aria Iiy. Il.l -- Habilabfe ruunl count
(irois Ii%ing .vea I iy. Il.t _ .... . -- Number of hCdruoms
Number of IircplacCs .. .. _ -- Number ol'ha11 K1111s
♦wnhzrt,fbathroolus , , Nunlberol'Jccki, parchci
f� pa of hC.lullg i>`Icnl I'nclo,cJ .(then
11 I`a„I C,`Ulllig i\UCIII
I
1 .,l LII I'f„�eGl \,hlafe Ith,l•1ga III;1\ 1,¢ illhdll lllcJ Iar..total Proj"I l 1,1••
CITY OF SM.E.M. 2NIASS.kcHUSETI'S
8cimL`G DEP.\R- IE2NT
3 I�� 120 W.AsmLNGTON STREET, 3iD FLOOR
T EL (978) 745-9595
F., x(978) 740-9846
j<I\tIiERLEY DRISCOLL
bL1YOR Trio.%w ST.PIERRe
DIRECTOR OF PUBLIC PROPERTY/BhILDL\G co%L%ussIoNER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of tMGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler) ,
The debris will be disposed of in
----- (name of facility)
— --(address of facility)
gnature of permit applicant
date
dcbro�ird,m
/moor CITY OF Siir .EM NL LxSSACHUSETTS
t, BL:IIDING DEPk?TNLF—NT
`• N 120 WASHCJGTON STREET, 3'a FLOOR
3
TEL (978) 745-9595
F.-,X(978) 740-9846
KI\fBERLEY DRISCOLL
MAYOR THoMAS ST.PiERRB
DIRECTOR OF PL BLIC PROPERTY/BCILDLNG CO\L\IiSSION ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/EtectriciansiPlumbers
Applicant Information Please Print Le pi
Name(BusinesaOrganizatiomindividual):
Address: L � r�f/Y `' tP
City/State/Zip: <<� �Af� at,& Phone M: L �olk
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with 4. 0 I am a general contractor and 1
Crployces(full and/or part-time)." have hired the sub-contractors 6' ❑New construction
2. 1 am a sole proprietor or partner- Iisredon the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. workers'comp. insurance. 9, 0 Building addition
[No workers' comp. insurance 5. 0 We are a corporation and its -
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'comp. C. 152, 41(4),and we have no 12.M"Roof repairs
insurance required.) t employees.LN'tawarkers'
comp, insurance rcquin:d.j 13.0 Other
•Any applicant dun chucks box sit mart also till out the aeclioo bclowshowing their worken'compensation policy innutnatlam
'I4saceownen wha xuh oit this Affidavit indicating they auditing all work and then him out,idecontmotors mint submit a new affidavit indicating such.
('miracwn that ch vk this box must anachrd an additional shut showing the narne or chi rub.:antntlan and their worked'comp.policy intertnation.
l am as employer that Is providing workers'c ompensa llaa lasurunce for my employeev Below 1s the polley and fob site
inforarariam /
Insurance Company Name:_v//t c I( C e—
Policy 4 or Self-ins.L.iic. d: (� Expiration Date. /
Job Site Address: i _L e)(YI* rj'll City/State/Zip; ,VQG°,1L'LYt
,%ttach a copy or the workers'camp nsation policy declaration page(showing the policy number and expiration Bata).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 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 S250.00 a day against the violator. Ile advised that a copy of this statement may Ito forwarded to the Oft ice of
Invcstigaliuns ofthe DIA for insurance coverage verification.
l do hereby certify t r th uins and ernaldes of perjury that the htforarutlan provided abuvvf is true and carrecit
D
5i t / 12—
Dare: �fS
01jiciul use only. Du not write in this area,to be eonnpleled by city or town offlcial
City nr'1'uwn: Pcrmit/r.lccnre q
Issuing Aulharity(circle one): — -^
1. Irourd of health 2.Building ilepartillent A.City/fuivn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact 1'eno°' Phone it!