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1 WILFRED TER - BUILDING INSPECTION 15 2-0 GKli:6gv � The Commonwealth of Massachusetts Board of Building Regulations and Standards RECEIVE ERV OF Massachusetts State Building Code,780 CM%S?ECT1t*PAL " IALEM Revised Alar 2011 Building Permit Application To Construct,Repair, Renovate Or Dens>,t One-or Two-Family Dwelling p�q This Section For Official Use Only Building Permit Number: Date Applied: �f 15 14 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers - / G /16ngd :J1i/— Lla Is this an accepted street?yes X no Map Number -Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(ft) 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: Publicl;r—' Private❑ Zone: _ Outside Flood Zone? Check if yes❑ MunicipaodOn site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ow err of Record: 7e_ M• C/q{jC Sa `7� © lg70 Name(Print) City,State,ZIP allI4yel Ae 9��- s3�z�9y I No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building wner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other pecify: O!J /' Brief Descr'ption of Proposed World: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: F5. Mecha trical $ ❑Standard Cityfrown Application Fee ❑Total Project Cost'(Item 6)x multiplier x mbing $ 2. Other Fees: $ hanical (HVAC) $ List: nical (Fire ssion) $ Total All Fees: $ 6. Total Project Cost: $ Check No. Check Amount: Cash Amount: qQ ❑Paid in Full ❑Outstanding Balance Due: m>al (-Eul C.l zz SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Ne of Moy-hoo I(x S License Number Expiration Date Name of CSL Holder^�v (J 6[ QI � �{— List CSL Type(see below) No.ap�pd She J [yv /t1 Type Description i.�q8 ell/ r Nn 01166 U Unrestricted Buildin s u to 35,000 cu.ft. City/Town,State,ZIP . _ I R Restricted 1&2 FamilDwellin M Masonry y RC Roofing Covering WS Window and Siding /Q/ SF Solid Fuel Burning Appliances jJ tJ�jl! 1 / MO 0 I 4 S)9 I Insulation ele hone Email address ,CO D Demolition 5.2 Registered Home Improvement Contractor(MC) / OTAIV Rim' a.S of boyL y.- Ex'�ta'!5 C Registration Number Expiration Date Li HIC Company Name or IRC Registrant Name No.and Street Email address Ci /Town,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 .......... 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 7T�Xgt'frY*''r /HUl�L� to act on my behalf,in all matters relative to work authorized by this building permit application. Pnnt Owner's Name(Electronic SigilaTurey Date SECTION 7b: OWNERS 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. 75!�P - �� 9 9-z0/z/ Pon[Owner's or Authorized Agent's Name(Electronic ic­Signature) 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.t4ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,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.ULEti1, iNLkssAcHusETTS BLHMNG DEP1RT%tE�iT 130 W 1 HINGTON STREET,3'O FLOOR TEL (978) 745-9595 FAX(978) 744-9846 KIMBERLEY DRISCOLL MAYOR T1Homa ST.Pwan DIRECTOR OF PUBLIC PROPERTY/BVIIMING CO%LNtISSIONER 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 I 11,S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in 4VW5'>4r om Se�C— (name of facility) (address of facility) sigoahire of permit applicant date debri�ffdw . % CITY OF 5� �i, ti'LkSSACI- US=S • BUILDING DEPART%MNT 126 WASHINGTON STREET,ase FLOOR 'ISL (978)745-9595 FAX(978)746-9846 tCl\�F-IItI.EY ORISCOLi. NMAYOR `I Homo ST.PmRRs DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG CONU6MIONER Workers' Compensation Insurance Affidavit: Buildere/Contractors]Etectrielans(lalumbers Anplicant Information Please Print,LesIbly dame(BusittessYDr0aaizatiotvindivit41a1): `e1lA'rip-+-� / " tO✓ TSoc/ 1 Address.---:fPill °L / c�'�• - /l �Y® City/State/Zip:-_ 2cr��Yi !!M' o/&4� Phone#:_ Are you an employer''Check the appropriate box: Type of project(requiref; Ln I am a employer with 4. ® 1 am a pccesl contractor and 1 6. ®New corsauctios employees(fart andlor part-time).• have hired the soh contractors 2.0 1 am a sole proprietor or partner- listed an the attached sheet.+ 7. ❑Remodeling ship and have no employees These sub�contmctars have 8. Demolition working for me in any capacity, workers'comp,insurance, q, Eiuilding addition (Nn workers'comp. insurance S. a0 We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a humeownct doing all wont light of exemptior.per MOL I I:0 Plumbing repairs or addition myself.(No workers'comp. c. 152,§I(4),and we have no 12.0 Roerrepairs insurance rcqui eed)t employees.(No waritors' 13. 00ter�0_6 'rl comp.insttrarrce requirede •Any Applicata 1hW chits box a 6 MMI also,fill cut the section he". showica rbcs wMkas'tvmpcvtxriton policy infwrtadoty '9lttmeawnrn who submit this arfldtva iadloting they am doing all work and then him cunide rmtemetors must submit a neve an(tlavit irAiatins Ards :Cenerrwo that cheek this hon mtne anachad on aMtionel¢hoer ehawing the twee of an mbS tta,was=4 their warken'carne.policy infcrtttntiaq. lam an emplayer that h providbt�workers'compensation hasaronee jarTroy employees Below la rise pulley and job sire information. Insurance Company Name: Policy#or Self-ins.Lic.#/: /p Expiration Date: job Site Address:_--_/ lt//C/rs�ot �e�r� . City/Statc/Zip: 0/t?G7 B Attack a copy of the workers'compensation policy deciaration pais(showing the policy number and expiration date). Failure to secure cuvclage as required under Section 25A of MG1.c. 152 can lead to the imposition of criminal peraltica of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in Ore farm of a STOP WORK ORDER acrd a free 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 vrritie:ation. I do hereby Certljy under thepain and penalties ojperjury that the itrfarmadon provided above is true and Coor/reef • t tr: � �— ��20J7 ;, nate ague a. r'a--ley / -_ - - O�Tsia!we only. Do not write in this area,to be completed by City or lown 00%claL City or Town: Permit/t.lcense# Issuing Authority(circle one): f I.Hoard of Health 2.Building Department 3.Cltyffown Clerk 4.Electrical to pectar 5.Plumhing taslmtor i 6.Other Contact person: Phone#t