0078 WASHINGTON SQUARE EAST - BPA-10-716 Y_tvt UR TWO FAMILY DVVF!_!_Atd
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' Oos and Standards --
- Massachusetts Stabe Budding Code t /
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VA ORDEMOLISHAONEORIWOFAM'LYDWELLING
Building Permit Nu r.
Son rOffical use Only
\h\� Date Issued:
I� Signature .
\Y soaaATIO -
II Inspwor
SECTION 1 -SITE IN RATIO
LI Property Add
/�/� 1.2 Assct
V san Map+Parccl Nombcr
v Mep Nvm� -
rarrdNomb<r
1-3 Zoning Information
1.4 Property Dimensions
- Trmiug District �---�_ .
. - P'°Pos<d Ilse(Na of dwdlivg) I,ot—,�t— s— (�--
IS Building Setbacks Frv¢t
Front Yard
Required Side Yard
Provided ..��� Rear Yard
.. - Provided Required
Provided
1.6 Watcr Supply-C.L t-44D.S S,. 1.7 Flood Zone Dnformatiou
Public ❑ Private Eli.f Sewage Disposal Systems
1.9 Special Permit Zoat N/A ❑ Municipal ❑ Sep6c.aystem ❑
Date Filed 1.10 Old+Historic Commission
I'll Cons<rvatiau Commission
WA El Number WA ❑
ECTION 2- Number N/A ❑
PROPERTY OWNERSIft'I AUTHORIZED AGENT
2.1 Owner of cords r�
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Addrry fa Sernce
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2. tborized Ag<ut //JJ
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earc Tdcp*ne
ECT10N 3 CONSTRUCTION SERVICES -
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ECTION 4-WORKER'S COMPENSATION INSURANCE AFF10AVfT(MG.L c 1S2 S 25c(6)) +' _Driers Compensation Insurance affidavit mts(be Provide this affidavit will result in completed and submitted with thisa
ialvf-of -I n-F-ailure-t .
-- e m 1 mg permit. � .
Igned Affidavit Attached
Yes_..... No--...- U
ECTION 6-DESCRIPTION OF PROPOSED WORK(check all
cw Cooshvction- applicable)
❑ Esisitiug Boildieg Repairs) ❑
Altmtioo(s) ❑cccsso ry Bldg. ❑ �
Demolition 1 ❑
� Addition
Spcci fy:
Brief D ription of Proposed Work'
�f/ C LJ n ✓ alelv✓i
ECTION 6-ESTIMATEDCONSTRUCTION COSTS
Item Estimated Cost(Dollars) OFFICIAL USE ONLY ..
I. Building
�n (t)Banding Permit Fee
W�Elttlical Multiplier
. A
1% (b)Estimated Total Cost of
Plumbing Construction from(6)
.
Banding Pumlt
Mechanical(IiVAC) (a)_(b)
Fin PC otoctiou
.Teta l=(1 +2 1 3+4+5)
Check Number
ECTION 7a-OWNER AIfTHORVATION-TO BE COMPLETED WHEN
W NER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT FO
hereby authorize .as Owner of the subject property
afters I 're to wo c uthrized by this bWdin to act on my behalf. In all
o
J / g permit application.
Srgaalare of chum<r /F
ECTION 71J OWNER/AUTBO --
ZED AGENT:DECLARATION -
ereby declare that the statements and Information on the foregoing application are as Owner rAuthorked Agent
'my knowledge and belief. true and accurate to the best
Ign u r the pains and penatti
fperjury. _. .. _._.
sisaatar<o>��rA� 0?02 0
Da
ECTION 8-NOTES AND FXPLANA770NS
Fees: The amount Of foes shall be$151$10W(Building:$10;Wiring:$3; Plumbing:$2)based on the total cost of
the work performed and materials used In conjunction with this
Minimum Fee; S30 Permit as estimated by the Building Official.
The Commonwealth of Massachusetts
.. .. Department oflndustrialAccidents
ir. Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AiMicant Information Q I Please Print Le 'bl
a aName (Business/Organization/Individual): r t' lv
Address:_/c ! gyt 460 n 7�
City/State/Zip: 11,11A
Are you an employer? Check a appropriate boa: Type of project(required):
1.❑ I am a employer with 4. ❑I am a general contractor and 1 6. ❑New construction
(employees(full and/or part-t me).* have hired the sub-contractors
2.ILXI I am a sole proprietor or partner- listed on the attached sheet. 7. Remodel ng
V _ship and have no employees These sub-contractors have g. ❑Demolition
working.for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp.insurance comp. insurauce.t
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their l l.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infannation.
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit anew affidavit indicating such.
iContmctors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contactors have employees,they rqust provide their workers'comp.policy number. '
I am an employer that is providing workers'compensatio insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
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$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. 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 cer ' u e the pains and pen o the information provided abo a is tru and correct.
IIC<
Signature: Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.PlH]Ihnspector]
6. Other
Contact Person: Phone#:
I 1 N 1242 W4242
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LS36R 24.DISHW B12R
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N 330
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All dimensions size designations given are This is an original design and must not be Designed: 1/23/2010
�+ subject to verification on job site and released or copied unless applicable fee has Printed: 2/22/2010
adjustment to fit job conditions. been paid or job order placed.
I MAN LUW
KOCHANSKY All(no dims)I Drawing#: 1