17 1-2 SUTTON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
W Q
\ s—, Board of Building Regulations and Standards
Massachuscus State Building Code, 780 CMR. T"edition Building Dept
Building Permit Application To Construct, Repair. Renovate Or Demolish a *kvos*WNM
One- or Tsro-Famih Duelling
This Section For OtTicial Use only
Building Permit Number: Dale Applied: d _
'v 2� v
Signature: �-
Buildi Cornmisvoner/I f Buildings Date
ECTION I: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1 r/7 5�N g✓e. Parcel Number
Ma Number
1.1 a Is this an accepted street?yesy�no p '
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sq ft) Frontage(fl)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40.Ss4) 1.7 Flood Zone Information: 1.8 Sewage D/layosal System:
Zone: _ Outside Flood Zone? Municipal[Zf On site disposal system ❑
Public f� Private❑ Check if esQ--�
SECTION 2: PROPERTY OWNERSHIP'
--------------------
2.1 Owner'of Record: l 7 rL S J
ntl/G/5 SWENBFtK Address for
GService:
��Naqm��e(Print)
'7-N—,7Y
S —'2 2 '7 1
S ure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construclion❑ Existing Building O Owner-Occupied Repairs(s) Alterations) ❑ Addition'❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': �rT�fr'L ,�4-- ti,� 'ZElar/R"�.�I' A.1�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Malcrials2.
I. Building f � p{)r/ I. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) $ List:
t .Mechanical (Fire S Total All Fees: f
Suppression)
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: f 0 Paid in Full 0 Outstanding Balance Due:
r ,
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CS 6673y rfehot r
License Number Expiration Date
N.4rnc of CSL-fjpldcr List CSL T ype(,cc helow)
t T Description
Ll=fenAddress Unrestricted u to 35.000 Cu. Ft.)
N R I Restricted l&2 Family Dwelling
S,gnamrc .M Masonry Only
j'7g'7 NT—316-el RC Residential RooOn Covering
Telephone wS Rcstdetnial Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 egBter Home Improvement Contractor(HIC) /
a C
HIC Compan Name or HIC Registrar(Name Regisuauon umber
Addrc
�/w&FP-A 04 . 47—,11'7 e/S—*f1 Expiration Date
Signature /1 1 Telephone f
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 .......... O No........... O
SECTION 7s: 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.
Signature of Owner Date
' SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
r�J�
1, "�*5� ,as Owner 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
behalf.
4.
Print Nam
Sigmmrc of Qwncr or Authorized Agent Date
(Signed under the pains and penalties of peru
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 a have access to the arbitration
B
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 I 10 R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ff.) (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 healing system Number of decks/ porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage"may be substituted for 'Total Project Cost"
CITY OF SALL•'M
PUBLIC PROPRERTY
DEPARTMENT
III 're 'r: ;.,: • I �� •,'v '�_ .1„
Construction Debris Disposal Aflidasit
(rcfluircd fiir all demolition and rcnu\if work)
In aecurtlance \\ il, the sixth edition ol•the State Building Code, 7S0 CAIR scctlon 1 1 1 5
Debris, and the provisions of SIGL c 40, S 54:
Building Permit to is issued with the condition that the dchris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will he transported by:
Inamc of harder)
1 he debris will be disposed of•in
hlame ur Iac I ny)
F�E,u�rrf' ►,^,�
I.Iddre" ul-I,K llllvf
.�U'wfulc of pcln ut Jill
Z I -0
Isla
CITY OF S-U-E.NI, UNSSACHL;SETTS
BL'IIDLYG DEPARTMENT
vv . )2Q WA6MINGTON STREET. Yo(MOOR,
TEL (978) 745.9595
FAx(978) 740-9846
KISBEALEY DRfSCOLL
TwhtAS ST.PMItRs
.%4AY011
DIRECTOR OF Pl:BLIC PROPERTY/gCQ.DLVG CO>L%rtS510%'F1
Workers' Compensation Insurance Affldavit: Builders/Contractors/ElectriciansiPlumbers
%pplicant Information ���� Please Print Legibly
Naine IBusirw».Organtrariorolndavulual): 1 kn& C'Gkt/9JQiA'L 7-/L6 fI`C.
Address: t �U7 � r�lrlE
City/State/zip: <ALAw MA. Phone N: fW— —7 E- �S�
,%re you to employer!Cheek the appropriate twat: Type of project(required):
1.❑ I am a er with employer 4. 0 1 ant a general contractor and 1
P Y b. ❑New constructionemployees(fWl and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor Air partner- listed on the attached sheet :
7. demrxkling
hip:and have nu employees These sub-contrachws have d. ❑ Demolition
workingfor me in an capacity. rkets'comp.insurance.
Y P ry• ° 9. 0 Building addition
'eq worker'comp. insurance S. tJ We are a corhave
exercised
and its 10.0 Electrical repairs or additions
regwred.l officers have eaereixd their
3.❑ I am a homeowner doing all work right of cxemprion per MOL 11.0 Plumbing repairs or additions
myself.[\'a workers'comp. c. 152.11(4).and we have no 12.0 Roof repairs
insurance required.[ t employees. LNo workers' 13.0 Other
comp. insurance required.)
-Any applicant the Ch"JIS Dag el mud alga fin twig the tecilm below showing'hair works t'compsnaaeion Policy infuntalba
r I I.aneuwnaa who udnnit this aeldevit indicating they ars doing all work and the hits outride tontrocaon'rant ruhmh a new affidavit indicting wnLL -
:r.mI:•don thM chawk this bag mud attached an a"tionid.Irk showing the tame old*aabK racaor i and their workea'comp.policy infoomtatica,
l one am employer that b providing,workers'coneprrrradoa lnswraweaJer sty employees, eduw is fhe pd/ty awdM s/le
information.
Insurance Company Name:
Policy N or Self-ins. Lie.N: Expiration Date:
job Site Address: City/state/Zip:
.mach a copy of The workers'compensation policy declaration pap(showing the polky, number and espiradon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
tine up to 51.500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a ring
Of up to 5250.00 a day against the violator. Ile advi.,kW that a copy of this statement maybe furwardcd to the Office of
I nvc�iigariona ul'dte DIA for insurance coverage vcritication.
/do hereby cerpo molder the pains med penalties of per/mry that the informatiow provided above is true and correct.
-7
O1ricial use only. Do nor write in rhir arse, ro be a arirpletd by city or toww ilf7ci IA
i
City or (oven: _ Permit/I.Icenfe N _ _
Issuing.\uihortly (circle one):
I. Iluard of Ilvallh 2. 9uilding Deparlment .). Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Qlhrr