5 WILLOW AVE - BUILDING INSPECTION --- I'lie Commonwealth of blaSS;lchusclls
Board of Building Regulations and Standards CI'I'1. OF
11,/ slti Massachuscits State Building Code. M C NIR SALENI
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One.or Tu o-Family Duelling
This Section For Official Use Only
Building Permit Number. Date Applied: —/
Building 0I11cial(Print Nmne) Signature )rot.
SECTION I: SITE INFORAIATION
I.I Property Address: 1.2 Assessurs Alap& Parcel Numbers
$ i-wrllR� �i �r
I.la Is this an; i; led street? •es no Nap Numher Purccl Nntnber
1.7 Zoning Information: 1.4 Property Dimensions.,
Zoning District Proposed IN, Lot Area(sq 11) Frontage 111)
1.5 Building Setbacks((I)
Frunl Yard Side Yards Rear Yard
Required Provided Required Provided Requind Provided
1.6 Water Supply:(M.G.1.c.40.§Sa) 1.7 Flood Zone Informallon: 1.8 Sewage Disposal System.
Potblle❑ Private❑ Zone: _ Outside Flood"Lune?Check ifyes❑ Municipal❑ On site disposal s)stem ❑
SECTION3: PROPERTY OWNERSHIP'
2./1�Ownert of Record,
l-:Rn/ ,C.urai� .S.�1e..-r H1�j. G i47ts
Mane(Print) City.Slate,ZIP
G✓r �/o � /FVe
No.and Street relephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Allerotlon(s) Cl Addition (03
Demolition ❑ I Accessory Bldg.❑ Number of Units_ I Other ❑ Spccily:
Brief Description of Proposed Work': a /W Cc c%a f/,,r..!6 zr s o N Iv
SECTION 4: ESTIJLATEO CONSTRUCTION COSTS
Rein Estimated Costs: Ofllclal Use Only
(I.abur and klaterials)
I. Building S 6v 1. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard CitytTuwn Application Fee
❑Total Project C-ostt I Item 6).1 multiplier
I I'IumMn4 S ,. Other Fecs S_ —
J. Mcchanical ill\ \('I 5 List:
1u +ressmn 1 rota) \11 Fees: S -___----
('hcck No. ( heck .\nxnum: h \m nml:
(� tidal Project CnvC_ i ❑ P.tid in Full ❑Uulslanding Ilal,mce Due,
�� 1Z 9 7ae- C,&X - ����
SEC]IONS: ('ONSI-Rli('TIQNNF.RVII'F.S
S.I Construction Supen isor License St.)
U$ Zz 6z /( -0
06 ee6Z I Iceuec Nuulhvr I Npirninu bate
.X;uneul'l'S1 Iloldet I vtl'SI. I)pel�evhelusv)._ ��Ks�..KF
fs Ucscription
Na ,uIJ Street
Windo
o
�J 11 1 innstricteJ I IIuilJin s li l0 1S,I111U cu. 11.1
./P,tl fir! O /QIJ�__. R t(c.trioed ll? I.Inlil 11"Alin
l'ilsi l'au .. Saae,ill' %I Nilson
RC Roolin l'uwrin
SF SuliJ Fuel 1 'ruing Appliances
I Involution
Tel. bony I(mailaddress D Demolition
5.2 Registered Ilume improvement Contractor(HIC)
,-)—, /, /7-c,-i P 6 • /7-4 I Ill'Itegislnnliun Numl+vr livpiruliuu Uuty
I IIC Contpan) Nanic or I IIC 1 •gistrunt Numv T a
�9' Ch d' 1L c?ei�i 4! h�I� sl,� vree e9
Nu. wld Strvct Einuil address
vr-!
Ci !Pawn•stale IP relc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. I52.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atlldavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........Pf No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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.
0—C.� I L; v ,r1, �y 1 S /Z
Print Um s Nwne lElcctrunle Signuturc) Data
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.
__ s, 1-2-
Print Uancr's a uthort/ad Agam'e NJmv I Electronic Sigileturv)--_--.__ Date
VO'PES:
I. .\n Owner whu obtains a building permit to do his.her usvn work•or an owner who hires an unregistvred cuntraetur
I not registered in the Hume Improvmnent Contractor(HIC) Program),will M) have access to the arbitration
program or guarut) fund under\1G.L.c. la?A. Other important information on the HIC Program can be found at
I Information on the Cunstruction Supervisor License can be found at 11Is.s nie.: .10% ,fit,
\1 hen substantial work is planned, provide the inlurntation below:
fulJl floor are Is{. tl l . !including garage. tinishcd basementatics.Jerks or purchl
Gruii lis ing Brea 154. IL 1 --- Ilabimble ruum count .-
\unnheroflircplaees ._. ._. . Number tit'bcdrooms . . . .
t \uohermhathrounls - y_ \wubcrofh;dfhaths
I\pcotheelingi)stem . . \untheroldel:ksporcllcs
It
' I\pe oI %;t4lhltg i\Qel❑ I!IIcI1+Cd ( ell
1. "l oral Projve t `;,lithe 1:oolacc '111;1l itc iilh,itititeJ ttir"l'otal Project(',,it'*
CITY OF S.u.E,�i, N LISS,WH US ETTS
t3UOL`IG OEPANME.Nr
1 _'0 W..U.4vGTON Srxw, PeaccA
I12L t978) 741.9595
KI113FRr RY OUSCOLL P.Vt(973) 14a9846
N YOR ITtO.AUST.?MAAS
Otawro x OP AL SLIC PRcpLrATY/at;QALVG Co3LAIISSION E q
Construction Debris Disposai Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coder 780 OUR section 111.!
Oebrisr and the provisions of MGL a 40. S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall be disposed of in a property licemed waste disposal facility as defined by&IGL c
111. S I30A.
The debris will Pbe transported by:
(name of hauler)
The debris will be disposed of in :
IJdnrr of f�� L�y)
Myna Nrs off if rpphcmf
J�:e
< Q-CY UN &UEM, AkSSACH[:SE"ITS
l)L'lLO1NG DEP.\R"C\IENT
�,';t•';k'j.. +� 120 WASHLNGTON STREET, 3w FLOOR
TEL 978 745-9595
F.kx(978) 7 W-9846
j_\j3 RI F.Y DRISCOLL 'HOSI.ssST.PIER"
NLslyox DIRECTOR OF PUBLIC PROPERTY/0taI.DiNG CONLMISSIONER
Workers' Compensation Insurance Aff1davit: Builders/Contructor4iEfectrfct•rns/Plumbers
lipolicant Inform-Ann Please Print Lefzlhlr
Naint: w
Address: 3� c /?vsc �(G 13 e � �.• t'r� �4
CilylStatc/Zip: Be,e,-6 Phonelf: /;76 Sc
Are you an employer!Check the appropriate bon Type of project(required):
I.❑ 1 am a umploycr with 4. ❑ 1 an a general contractor and 1 6. ❑Now construction
dotployces(Nil and/or part-lima).• have hired that sub-contractors
2.01 am a sole proprietor or partner- lived on the attached sheet. / I. ❑ Remodeling
.hip and have no employees These sutr-contractors have g. ❑ Demolition
working for me in any capacity. workers'comp,insurance. 9. I] Building addition
(No workers',comp.insurance J. ❑ We are a corporation and its
requircd.j officers have exercised their MCI Electrical repairs or additions
).❑ I atn a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.f\o workers'sump. c. 152,§l(4),and we have no 12.0 Roof repairs
insurance required.)t employees.(No workers'
comp. insurance required.) I7.❑Other
•.\My applk:ott thus ehwYr but II mass alao all out the scuiue balow.havii"s their watimrs,compensation policy mnutnetton.
'1 huneowners who•uhmif this stllAnvis indicating they an doing all work and then hire wnids contractors mime mhmil a new anldavil indicating.uch.
:l•ondmmun that chalk this box moat.maahwl an.dadflturtul.hsl Showing that Mena orthe cubwunrrackn and their workan'wmp.policy intaemadoe.
fain an rurpluyer that is pruvidrrX rvarkas'cumprnsadun huuranee jar my ernpluyrrs. Below is the policy and job site
injarnrution.
In,omnce Company Name: 010 a . Cif _Zc-=
Policy 4 or Self-its. Liu. it: Expiration Date:
Job Site Address: S, a 14V r— Cityistatei2ip:
Attaeh a copy of the w rn workers' copensatloi pulley declaration page(showing the policy number and expiration data).
Ktiluru to,ovum cuverage as required under Section 2JA ot•3tGL c. 152 can toad to the imposition of criminal penalties of s
fine up to i I,JCO.UO and/or one-year imprisnnmcnt,as well as civil penalties in the form of o STOP WORK ORDER.arid 4 lino
of up to i'-J0.00 1 day sgainst the violnror. Ile advi.+ad that a copy of this.,tatement may bat iurwarded to ilia Of 0ca of
lavv,tigltinns of the MA ter insurance coverage veriticaliure.
i,lu/1errby reriljy under the point mid penaldes""perjury/but the hifur tutlam provided above it rime Turd Corriere.
rr�e,f: 7f 305! 6f'67
011hial u,e only. Oa net write in duly area, to be Completed by city or town raj/h'ial
I'ermiriLlccnye i
I„uia„\ulhurily (circle nnu)t —._.
I. L'oard ul Ilcullh I. Iluildln., 00parimenl I. (ityi Town Clerk 1. f.Ieetrical bi liccrnr i, Plnmhint: Indpeetur
lie. Other