25 UPHAM ST - BUILDING INSPECTION -7230- ! �7 012 7C)'
The Commonwealth of Massachusetts `/t D
11 Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR SAL pareP ar..201� ER���ES
Building Permit Application To Construct,Repair,Renovate Or Demolish a `Y R - 1
One-or Two-Family Dwelling so
This Section For Official Use Only
Building Permit Number: Date Applied:
1 �
Building Official(Print Name) Signature ,Dat
SECTION 1:SITE INFORMATION
1.1 P perty Addre 1.2 Assessors Map&Parcel Numbers
L l a Is this an acce ted street?yes c/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards 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:
Zone: _ Outside Flood Zone?
Publics Private❑ Check if es❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O er'of Record:
��rs c f W- 6 "A C�t4 J�
Name(Print) City,State,ZIP
t06- U' C 7b'-1SIU-41"
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) 151 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed work2: S L j.2 1 -e— 600
l SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ �q 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ QU ❑Paid in Full ❑Outstanding Balance Due:
�l1 I N A 0p�-A 0 P_ Z
SECTION 5: CONSTRUCTION SERVICES
f 5.1 Construction Supervisor License(CSL)
SCe 6� b j i License Number Expiration Date
Name of CSL Holder
/ -��4 I 0 UJ List CSL Type(see below) ♦J
No.and Street Type Description
14 (1- 7 d-A� U Unrestricted(Buildings up to 35,000 cu.ft.
Gown,State,ZIP R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
/ / ! SF Solid Fuel Burning Appliances
(t(/�" 7(ro)�'G ��u SdO�CJ L.O/�Y'4'lf re/ I Insulation
Tel molition
Telephone Email address D De
5.2 Registered Home Improvement Contractor(HIC)
S CO(} i tt.0 I HIC(Registration Number Expiratioh Date
HIC Company Name or HIC Registrant ame
SrL4j r 600 cCciJI-_lLef
No.an
14 6,,� 67 0-7(, &03 7v /c7o Email address
CityiTown,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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 ..........Er' 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Sk-t+rC r0H 6 ¢ / .
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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.
i� - y t/y
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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 heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.UX-NA 1, 2NAASSACHLSEM
BUMDING DEPARTNWNT
J 120 WASHINGTON STREET,San FLOOR
TEt- (978)745-9595
FAX(978)740-9946
KINIBERLEY DRISCOLL
MAYOR THOMAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONDIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Analicant information_- _ Plean Print Legibly
Name(BusinestiOrganintiotvindividual): ' COLL1
Address:
City/State/Zip:—CY. VIGt I,-- 1A Phone#:_ U 3 — �7 U
Are you an employer?Cheek the appropriate box: Type of project(required):
I.0 1 am a employer with 4. ❑ t am a gencral contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors 1 D%ling
2.El am a sole proprietor or partner- listed on the attached sheeti i aRir`
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. []Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and is IO❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL l If]Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' I3.❑Other
comp.insurance required.]
•Any applicad that ducks box rl must alas fill out the section below showing their workers'compensation policy information.
'Ibtm:owmxs who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new anidavil indicating such
:Comracton that check this box must attached an additional sheet showing the name of oho sal.,,amerem and their workers'comp.policy Information.
I am an employer that Is providing workers'compensation lnpurarrce for my employees. Below Is the policy andM site
information.Insurance Company Name: iCt,4%t (. AaJ-
Policy#or Self-ins.Lie.
f#: ff �tf U3 Expiration Date:—
Job Site Address:- (AN r 64 �A— City/State/Zip:
Attach a copy of the workers'comi6satlon 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 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. He advised that a copy of this statement may b:forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby
re• cert/ify ader the pa, s and penoldes ofperjury that the information provided a ova�a rue and correct.
Signau Data,
y
Phone
OJrriol use only. Do not write in this area to be completed by city or town official
City or Town: Permit/I.Icense#
Issuing Authority(circle one):
1. Board of Ileallh 2.Building Department 3.Cityffowu Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other,
Contact Person• _ Phone#:
CITY OF Sm.&m. NWSACHUSETTS
BL'ILDLING DEPARTN&\''T
130 WASHINGTON STREET, 31D FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KI\(BERL EY DRISCOLL
MAYOR T HoNtns ST.PtERRe
DIRECTOR OF PUBLIC PROPERTY/BL'1LDING COMLMSIONER
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 MGL 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 wi H be transported by:
(name of hauler)
The debris will be disposed of in :
(name of facility)
tl C41 /j
(address of facility)
signature it applicant
'L/jd/V-
date