3 VICTORY RD - BUILDING INSPECTION EITy-OF
PUBLIC PROPERTY
o.
DEPARTMENT
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NAYOt 120 WeaaluaroN S'IAFEC '
ALEK X&%UaiLW 1-M 01970
TO-979-74S-9S9S*Rex:97b740.9g"
APPLICATION FOR THE REPA_I- RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name:
Building;
k
f Property Address:
Property is boated in a;Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name:
Address: ��
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXIST MG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (SO Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
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-- Mail Permit to: -� t -- --
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What is the current use of the Building? dwelling, ununits?---
Material of Building? v w hooww many
Asbestos?
Will the Building Conform to Law?
Architects Name
Address and Phone
Mechanles Name
Address and Phone HIC Registration#
Construction Supervisors License#
Estimated Cost P ect S Permit Fee CakuWdon
Permit Estimated
$ Estimated Cost X$71S1000 Residential
Estimated Cost X$11/51000 Commercial
An Additional S5.o0 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perJurY /� ��✓�
Date
0
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CITY OF SALE.M
PUBLIC PROPERTY
DEPARTMENT
waa�an.av carronL
Wvoa 17a WA"WG=n Sn=•SMEW HASACHLSKI 101WO
Construction Debris Disposal Affidavit
(required far aU demolidon and renovadom work)
In accordance with the si7tt6 edition of the State Buildins Codes 780 CNM section 111.5
Debris,and the provisions of UGL a 406 S*
BuildlnS Fortuh 0 is issued with tine condition thst the debris resuldn3 ftm
tiffs work shall be disposed of in a properly liceu tal waste disposal&ciUty as defined by MGM a
1 l 1.S 130A.
7 be debris wiU be transported by:
I(ham erg
The debris wi11 be disposed of in:
01tlu)Woe,
c'.�J4
(name of facili
(addmas of facility)
sip jalm of pem*aWLjcAm
V=2\,-U10
dam
tdd..dar
The Commonwealth of Massachusetts
Department of Industrial Accidents
�' Office of Investigations
Is'I 600 Washington Street
Boston, :11A 03111
www.massgov/dia
Workers' Compensation Insurance AffidaNit: Builders/Contractors Electricians/Plumbers
Applicant Information Please Print Legibly
Name business/Oreanization'individual): �It�
Address: 2p�-A��oc�l=�
City/State Zip:_ Phone 1 k,- `= LA- `51 to
Are you an employer' Check the appropriate box: Type of project:(required7):1. I am a e lover with 4. ❑ I am a general contractor and ImP 6. ❑ New conson
employees (full and/or part-time).* have hired the sub-contractors
=.❑ I am a sole proprictor, or partner- listed rn the attached sheet. Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolidon
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
[tio workers' comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152. §1(4), and we have no 12.❑ Roof repairs
insurance required.] + employees. [No workers' 13.❑ Outer
comp. insurance required.]
Any applicant that checks box#1 mum also fill out the section below showing their workers'compensation policy in Formation:
'Homeowners who submit this affidevit indicating they are doing all work and then hire outside contractors mum submit anew affida%it indicating such '
ontractors that check this box must arteched an additional sheet showing the name of the sub-contractors and their workers' comp.polic% information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. \ n-
Insurance Company Name:
Policy=or Self-ins. Lic. =: �F o k pq C( � Expiration Date: �j 1-
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation 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. Be advised that 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 the pains and penalties ofperjury that the information provided above is true and correct
Signature: Date
Phone
Official use only. Do not write in this area,to be completed by city or town official.
Cin or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. t?ther
Contact Person: Phone#: