3 SYMONDS STREET - BPA 16-171 to 3
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
M Massachusetts State Building Code, 780 CR S
Revised dM Marar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official U ly =
Building Permit Number:
Building Official(Print Name) Signaturei Date,
t SECTION 1:`SITE INFORMATION -• ` ' s
1.1 Property Addr s: 1.2 Assessors Map At Parce►Numbers `r rn
3 Sun.Addr S�' " `�,
s
1.1a Is this an accepted street?yes ✓ no Map Number Parcel Number Z
13 Zoning Information: 1.4 Property Dimensions: tv r
to
MCI
Zoning District Proposed Use Lot Area(sq R) Frontage(ft) �
1.5 Building Setbacks(it) c=)
Front Yard Side Yards Rear Yard '0
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❑
SECTI6Ni3: PROPERTY OWNERSHIP' ;
2tOwnert of Record:
AT TI2vR LLC 1IR MA Oalys
ame(Print) City,State,ZIP
a3 A144r. sJrU4 50 - 30Y-4 3 +Zr ,tr. rt_flr.all. Co,
No.and Street Telephone Email Adless
SECTION 3:D K ESCRIPTION OF PROPOSED WOR (check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ i Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Speciry:
Brief Description of Proposed Work : r¢,„ wall <Aanaa wCn dwr e.,d d"is new
i� � /en•�ei 1 h fliaa,»5 erg b,le.l, .,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item OfScial L1se Duly
Labor and Materials
1.Building $ 3 5 0 O O 1. Building Permit Fee:$ . i Indicate how fee is determined:
2.Electrical $ 5 O ❑Standard CityYrown Application Fee
❑Total Project.Cost'(Item 6)x multiplier x
3.Plumbing $ 7 S o Q 2. Other Fees: $
4.Mechanical (HVAC) $ 0 0 List: -
$.Mechanical (Fire $
Suppression) Total All Fees: $
S a CheC '0. Check Amount: Cash Amount.
6.Total Project Cost: $ D �l p paid m Full 0 Outstanding Balance Due.
M 0" `N�D
SECTION 5t ,CONSTRU.CTION SERVICES „
5.1 Construction Supervisor License(CSL) G
/ S -/d`l3lS 1�10linry
A) , h o v, S r w License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) V
a1
No.and Street , Type •='` Desenpdon _
17
5,000 cu.ft.UUnrestricted Buildin u to 3
goer�.,�� lt'I A 0/X3 D R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
4,)8, 9141 20kY NCtG lG +1�^rt'Nn(�?i �,,,,')•caa 1 Insulation
Telephone Email addr s D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
11
SECTION,6:WORKERS'COMPENSATION INSURANCE AFFII/AVIT(M.GL.e.152.§'25C(�)
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 ..........IV No ........... ❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED;WHEN'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize I}r<1 A/�/ O 2T (N f
to act on my behalf,in all matters relative to work authorized by this building permit application.
2Gjeev 1,' r 4 MGArAg,4 Menge/' - hR/ I
Print Owner's Name(Electronic Signature) Date
SECTION 7b:.0WNERr OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
,)rfaA Orf/1AS 2 /21I16
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dQs
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable mom 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"maybe substituted for"Total Project Cost"
b:
j
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERND117NG AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_ S G g r r o C o r I r a ch 9 L G C
Address: S-L r o roc S 1
City/State/Zip: H. cf L t// 10 A 019 3 P Phone#: 92.9 . 71 y • 1 a S y
Are you an employer?Check the appropriate box:
F14.E]Other
of project(required):
1.❑1 am a employer with employees(full and/orpart-time).• ew construction
2.pI am a sole proprietor or partnership and have no employees working for me in emodeling
any capacity.[No workers'comp.insurance required.]
3. 7 am a homeowner doing all work emolition
❑ S myself.[No workers'comp.insurance required.]t
4.❑I am a homeowner and will be hiring contractors to conduct all work on m ilding addition
Y Property. I will
ensure that all contractors either have workers'compensation insurance or are sole ectrical repairs or additions
proprietors with no employees.
mbing repairs or additions
5.❑1 am a general contractor and I have hired the subcontmaors listed on the attached sheet.
These subcontractors have employees and have workers'comp.insurance.= of repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. er
152,§1(4),and we have no employees.[No workers'comp.insurance required]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infomtation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
/Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ,
Insurance Company Name:_ jia e c log 5
Policy#or Self-ins.Lic.#: e F 419 eg 3 G 6PG Expiration Date: 3 A'Z//7
Job Site Address:_ 3 5 y. o- ) 5 f (.Sty/State/Zip: S..I c— . M 11
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under thepains andpenalties ofperjury that the inform ation provided above is true and correct.
Siyuature: i12./�— Date 2/
Phone#: S 7Y. 91Y 'L n rf y
O
fficial only. Do not write in this area,to be completed by city or town official
n: Permit/License#
ority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: 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 the
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 pemvt 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 pernut/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or I-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
A : Massachusetts Department of Public Safety
�= Board of Building Regulations and Standards
License: CS-109368 ~�-
y Construction Supervisor
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32 MUNROE STREET
HAVERHILL MA 01811 ;
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