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101 WEBB ST - BUILDING INSPECTION r The Commonwealth of,%4assaehusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALE[ (I Revised Mar 2011 JL Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Orily. Building Permit Number: Date App1 2d>, 21 Building Official(Print Name) Signature Date SECTION L SITE INFORMATION 1.1 Property Addre s: 1.2 Assessors hfap Bt Parcel Numbers -5'01-eGU L l a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes13 SECTION 2:; PROPERTY OWNERSHIP" ' 2.1 Ownert of Record: Name(Print) City,State,ZIP /6/ tab '{$ 57- F 7 • /� No,and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSEDWORW'6heck all that apply) . New Construction ❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ ration(s) ❑ Addition Cl Demolition Cl I Accessory Bldg. ❑ Number of Units Other Specify: R d)P-,, irP Brief Description of Proposed Work': LJn i O C_S'—� �7 sc : ^C-c— G'/-rigt.40 r SECTION 4: ESTINUTED CONSTRUCTION COSTS [reinEstimated Costs: Official Use Only-. Labor and �.faterials 1. Building $ ed I. Building Permit Fee.- S Indicate how fee is determined: ?. Glcctricul CT Standard,Cityi'rown Application Fee $ ❑'rural Project Cost'(Item 6)x multiplier x J. Plumbing $ 2. OtherFees: .S 1. Mechanical (IIVAQ S List: ( y+=� yh r1> i. \lech.mical (Piro - SnP pression) r7Q Check No. _ Check Amount: _ C Ish .\uwune_ -__-- n Il fal I'rnjcc[ ('oSh $ /`�®Q ❑ 11 kid in 1'nll Cl011tstandin� fS ilutce Una. 0MA dt'�' Oc'//t fry A/\'� SEcr[ON 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor Liecuse(CSL) G?5' C r t r— s< rs.� a� �� � License Number E.-virauu Ite Name ufCSL I lolde D� List CSL type(see below) Z2 alijj�- 57— .T e - Description No. and Streat �q q /' Unrestricted u to in U� to Restricted 13r2 Family Dwelling CiryL town,State, LI �-- Ibl \lawny RC Roofing Covcrin WS Window and Siding SF Solid Fucl Hunting Appliances �`Zr�"7yQn�al I Insulation Demolition l'ele huno Email address U Demolition 5.2 Registered Hone Improvement Contractor(IIIC) ©F. r H[C Registration Number sp' atiun Uate IIC ny�'Na�nII1C�Rcg�strm�tName 06Gi No. and S Emai address tre t C /Town, State, ZVP 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 o e building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a- O W NER 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. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED.tGEN,r 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. �' - f z y' v <`3 Print Owncr'i or AL I1urized Agent's Nanic(ElcetCUlll' Ignatum) 'Ite NOTES: I. :kn owner who obnins a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Haute Improvement Contractor(HIC) Program), will Lint have access to the arbitration program or guaranty fund under\I.U.L. c. 142A. Other important information on the HIC Program can be found at www oca Information on the Construction Supervisor License can be found at wlvw.ntay.v,�' dp_< 2 W'hen subst:utti;tl work is planned,provide the in beluw: Total tloor:trcn(s,l. lt.) ___ _(including garage, tinishud basemenVattics, decks or porch) iroi; living area(;y, ft.l _— -- Ilabitablu room count -- Nuwber,tf ti cplacus_,—-- Number of bedrooms Number of halCb.uhs VuwberoCbachrl�oms _--_ --- ------ — �'I?0 Ot ild.lh ll� iy;IClll NIIIIIh Cr Ut duck 'pUl'i 1Ci f',lie 01 c00161'1 il/'Mll Enclosed he sub;nnital I:,r..lm.11 I'nycd l',rs' _ . i }Vr CITY OF S.LfZNf, N -kSS.ICHUSETTS S [IODIC DEP.1RM&`iT 120 VV.NSNLNGTON STREET, 310 FLOOR TEL (978) 745-9595 KIMBERLEY DRISCOLL FAX(978) 7•10.93.14 NL3YOR TFIoxu ST.Pmn DIRECTOR OF PLOLIC PROPERTY/BCILDLNG COSOIISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) (n accordance with the sixth edition of the State Building Code, 780 CNIR section I l 1.5 Debris, and the provisions of NIGL 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 NIGL c t 11, S l SOA. The debris will be transported by: (name urhaulor) The debris will be disposed of in (name or racility) Vd W(Address ur(aaility) signature of permit applicant IAtc "- oi_21� CITY OF SiU E'),I, NL1SSACHUSETTS BUILDING DEPARTJ1EJir 120 WASHIINGTON STREET, 3se FLOORTEL (978) 145-9595 FAx(973) 140-9846 1KIMBERIEY DRISCOLL THO,%WST.PIERRB MAYOR DIRECTOR OF PL'OLIC PROPE0.TY/81i:I1DL`IG COSL�IISSIONER - Workers' Compensation Insurance Affidavit: Builders/Contracturq/Electricians/Plumbers 4nniicant Information Plcase Print Lee(bly �Iot11C(OwinvyyUtgtnirariurvindividual): t%F"r7'- jS��.10iY�yL � ��1es1���!� Address: 2� i4G� �� . gfgwlvGd U stew City/State/Zip &-irpj Phone c- /O 11 F in employer?Cheek the appropriate basis Type of project(required): a employerwith 4 4. 0 1 am a general contractor and 1 6. ❑New construction loyees(Rill and/or parttime).* have hirer!the sut►contraetors a sole proprietor or partner- lived on the attached.sheet t 1. ❑Remodeling and have no employees These sub-contractors have 8. 0 Demolition king fur me in any capacity. workers'camp.Insurance. q• 0 Building addition workers'comp.insurance 5. 0 We are a corporation and its required.) officers have exercised their 10.0 Electrical repair$or additions 3.0 1 sun a homeowner doing all work right of exemption per MOL 1 I.(]Plum •ng repairs or additions myself.(No workers'comp. c. 152,§1(4).and we have no 12. oof repairs insurance required.) t employees.LNo workers' IJ.❑Other, sump.insurance required.) •Any applic ns aaa viie ke boa 01 most also all uut ihv uvtiea blow showing tha4 warkma'mmynwlun pulley inlLrmatlo6 '1Lmeuwm"who rulmdt ihiutlldavit indlesting shay an doing all work and that him ouniG eantmetas most submit a nevi anldavit indieeeng ruck :0,nuxrun thal Owls ibis box most anachod m addidurvd chat showing Iho name of nib sutFedntnctam ad ihdr workere'sump.paltry Infomudoo. fain un employer that b provldln y tvonkers'ramprnrarlan lusurrrnce jar my empfuyerx Below is the polley urrd fob sits, lujormullono Insurance Company Name: Z±::A r/ Policy 4 ur Scir-hu. Lis N: Expiration Date: tub Sifts Address: /D/ �+ s City/StaWzip8.V 14.X4 Gf iQ A ttaeh a copy of the workers'compensation policy declaration page(showing the policy numbor and asipiradoa data) Failuru to scum coverage as required undcr.Section 2JA of MGL c. 152 can lead to the imposition ofcriminal penalties ors tine up to SI,500.00 und/or one-year imprisonment,as well as civil penildes in the farm of a STOP WORK ORDER and a line of up to 52J0.00 a day against Ilia violator. Ile advised that a copy of this statement may be I'urwurded to the oft ica of Invevigmium of iha DIA furinsurmua coverage verification /do lrtreby cerdf er dr%pstlns-mrrd penu/ties ujperfury'/rur fAe lnjunnuNmt propliZed above is true sued correct. , �'-. - i rri-r— Dar • r ht J: 5 7 e p i 011iciol use surly. Du nor ivrife in r/dv urru,ra bo cuu plrlad by city ur lawn n�JlrluC Ciryor'ruwn: Pcrm(r/Llcenre,Y 1s1u113g,lulhur4y(circle unc): -- — i I. Guard of IlealIN L.Iuilding Mpartntent I. Cltylrown Clerk I. Electrleal Lupectur 5. l'Iwnbin a Ion ector G.Other .__. b P Contact Person:. _ _. .... I'hana It'