37 TURNER ST - BUILDING INSPECTION 10
The Commonwealth of Massachusctts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7ih edition
"Permil
Building Dept
g Permit Application To ConstaeY-R r, Renovate Or Demolish a
One- or T�mnih Dwe/LTh Section For Ot7cial Us Only
e . Dat ppli
limr �t�- 7 mmissioner Inspecioro uildings Date
SECT 1: INFORMATION
1.1 Propperty Address: 1.2 Assessors Map& Parcel Numbers
_'S'7 TLL2N�/L S r,
I.]a Is this an accepted street'?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distnct Proposed Use Lot Area(sq R) Frontage(8)
P
lding Setbacks(ft)
Front Yard Side Yards Rear Yard
red Provided Required Provided Required Provided
er Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private ❑ Zone: _ Outside Flood Zone?Check if yesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 V,7'of Record:
KAKI ��tIGE��iZ( �7A,
Name(Print) Address for Service:
7P ! - 9'/0
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building M Owner-Occupied ❑ 1 Repairs(s);W I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Number of Units Other ❑ Specify:
Brief Description of Proposed Work': 12,919 L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building E 1. Building Permit Fee: f Indicate how fee is determined:
2. Electrical E ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S LChcck
S
4. Mechanical (HVAC) $
5. Mechanical (Fire S
Su ression
Check Amount: Cash Amount:
6. Total Project Cost: S $ZJ7JD 0 Outstanding Balance Due
c
r
J
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7(2 3 SD &Aar ?0
.. . 76350 ate
Lrntac Number Expiration Date
N.4mc of CSL-HpWer
n+ List CSL Type lscc below)
• y T/N s
Description
AddressU J Unrestricted(up to 35.000 Cu. Ft.)
Restricted I&2 Family Dwelhn
Signatur_-----��i/,J��/� ,N %lasonry,Only
��• p �2�/z��%�//L�Y� RC Rcsrdcnual RoofinCovering
Telephone WS Rcsidennal Window and Siding
�� — 3 S-3 SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.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.,..IV..... O No...........❑
SECTION 7a:OWNER AUTHORIZATION TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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 Ownef Date
SECTION 7b: OW`N,EW OR AUTHORIZED AGENT DECLARATION
1, R d y [AJY�J �1/fjlJ(1T6 , 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.
�F}`l trJ�fC/G'�ffrCzOTY1
Print Name r
JS`,�,�1�w6-
Signature of Owner or ut orized ent Date T—
Si ned under the pains and penalties of perjury)
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 no 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 110.116 and 1 l0.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces ,dumber of bedrooms
Number of bathrooms Number of half/baths
Type of hearing system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage' may he suhswuted for 'Total Project Cost"
CITY OF SALL•.M
r�y PUBLIC PROPRERTY
DEPARTMENT
.••I I.. \\ � . I:`. . ••'.1.iII f / \\II V. \I\,.0
Construction Debris Disposal Affidavit
(tc\luircd for all demolition and icnocation \vurk)
In accordance \\ilh the sixth edition of the State Building Code, 780 CAIR scctiun I 1 1 5
Dcbtis, and ill provisions of%IGL c 40, S 54;
Building Permil H is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
111, S 150A.
The dchris will be transported by:
1 / /l !'��yiA/T"yLtifi
Inane ut hauler)
I he debris will be disposed of in
Inane,o I]alnv)
MIL fi'Wf
Luldre<. ut Iac Jllvl
.I�n.JJwc nt pi WWII apphcJnl
C
IJIC
CITY OF S.UX- Yi, .\tIa-kSSACHt;SETTS
BL'IIDLNG DEPARTNMNT
12
0
WASHMGTON STREET, Sao FLOOR
TE1_ (978) 745-9595
FAX(978) 740-98U
Kf,BFRfEY DRISCOLI
'If
MAYOR toMAs ST.Pmlin
DIRECTOR OF PL BLIC PROPERTY/11 IIDLV G CO>LNQSSION FA
Workers' Compensation Insurance Affidavit: Guilders/ContractorslElectricians/Plumbers
Annlicant Information Please Print Leeibly
Nalne tdusim� Organizaiiomindry PAY f�AY /,4),5-NG 6,7t/AeF {
Address: 21,0 7�fD/Lv0/ 1G£ Si.
City/State/Zip: /3 y4L;z twA Phone #: 7P/ - D - ( 3 s 3
Are you to employer'Check the appropriate boa: Type of project(required):
1.0 I am a employer with 4. 111 am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.0 1 am a sole proprietor or partner- listed on the attached sheet : 7- ❑Remodeling
ship and have no employeea Theae subcontractors have g. 0 Mmolition
working for me in any capacity. workers'comp.insurattee. 9. 0 Building addition
[No workers' comp. insurance S. 0 We are a corporation and is I0.❑ Electrical repairs or additions
required,) officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. C. 152, 01(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers' 13.®Other Gt//os/OdtyL
comp. insurance required.)
-Any applica s ttua checks box Of must also fill our the seclim bci"showing their workta'con pensadon policy information.
'I hm owoen who suhtnit this allldevis indicating they are doing all work and them hiss outside eemrook"meat auhmil a new aMdsvit indicating such.
:rune melon cut check this box must attached an additional short showing tho name of the Nkionowsors and Iheir worlons romp,policy information.
I am an employer that it providing workers'compensation Insurance for my employees Beiew/s the policy and yob silo
information.
Insurance Company Name:
Policy N or Self-ins. Lic. M Expiration Date:
Job Site Address: City/State/Zip:
,\nsch a copy of the workers'compensation policy declaration past(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■
fine 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 i day against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of
Inccsugations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penaldes of perjury that the informadom provided above is true and corrrci
';wriawr Zkr,14,1!, t.
//
Phone 4 7�/ —/ 3T3 ,
iOfcial use attly. Do not write in this area, to be cunrpleted by city or town o/yiciuL
City or ruwn: Permit/I.Icemep__.
6suint Aulhonly (circle one):
L Board of llrallh 2. Building Department 3.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Gnitact Person: _. _ _ __, _- Phone lit: