6 WILLSON - BUILDING INSPECTION . �I 7S cK. Zss 3
The Commonwealth of(vlassachusetts
Board of Building Regulations and Standards Q CITY OF
Massachusetts State Building Code, 780 CMR 1016 Nov 1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Offioial Use Onl
Building Permit Number: Date Applied:
109149
I Building 011i6011(Print Name). Signature Date
SECTIONI SITEINFORtNIATIOW
1.1 Property Address: 1.2 Assessors blap& Parcel Numbers
to U, ELS L U t/�
I.la 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(sy It) Frontage(R)
1.5 Building Setbacks(It)
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:
Zone: _ Outside Flood Zone? Municipal(f`On site disposal system ❑
Public i5� Private❑ Check if yesE3
SECTION 2.- PROPERTY OWNERSHIP!`
2. Owner of Record: S
ntC AA es -e
NN me(Print) City,State,ZIP
W u,SOL 1-go s-ul �-�—
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Altemtion(s) ❑ Addition ❑
Demolition aT accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
QUTAT
t J2 Uvt't a I C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item
Labor and Materials))
V g
I. Building
I. Building Permit Fee:8 Indicate how fee is determined:
i 0(9
❑Standard Citylfown Application Fee-
t. Electrical 5 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing :S 2. Other Fees: $
d. Mechanical (HVAC) S List: /
5. Mechanical (Fire S Total All Fees:S-
Suppression)
Check No._Check Amount: Cash Amount:_
6.'rutal Project Cust: .S 0 ❑Paid in Full ❑Outstanding Balance Due:
MPAL-pro Tr�) CC . t\� zy
SECTION 5: CONSTRUCTION SERVICES ti
5.1 Construction Supervisor License(CSL) CS--L l O
R/ wnw ) en
l�P—Ixe License Number Exp a) tiu Date
N_am'c of CSL FloldAerl LisI CSL"f ype(see below) V
Type Description
U. and Street , .
p ,,qq ,1 yyyyyy U Unrestricted Ouildin s tip-to 35,000 cu. It.)
(:-L� /YIA l� R Restricted l&2 F:unit Dwelling
Cityfr wn,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/ SF Solid Fuel Ruining Appliances
Insulation
Telephone - Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Comp:my Name or FIIC Registrant Name
No.and Street Email address
Cityrrown,State ZIP Tel. hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G!E:c. 152.§ 2SC(ii)},
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Is3uance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATIONTo HE COMPLETED WHEN!
OWNER'S AGENT OR CONTRACTOR a L ES:F R PMDING.PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
D�L c
Print Owner's Name(Elec rani Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
er attest under the pains and penalties of perjury that all of the information
By entcrin y name below, 1 h
01
contain ii this npplic ton is u nd accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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(FIIC)Program),will nut 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
wsvw.mass.•ov:'oat Information on the Construction Supervisor License can be found at www.mas�
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. A.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
rypeofcoolingsystem Enclosed Open
3. "I'otal Project Square Footage may be substituted for"Total Project Cost"
"Oil
Massachusetts Department of Public Safety
j Board of Building Regulations and Standards
License: CS-084041
Construction Supervisor
'r.
RAYMOND M PETRELLO..
94 WASXINGTON'SL
TOPSFIELD MA 0198
I v -
j _
Expiration:
issioner 06121129i9
Il.V I7/;CdI,�l7.{J .61
Ow OF SALE9 MASSAMMn
1�L 7�-9995.
$i1�FYDRLS�[I PAXPM74069M
MAYCR 7tio�I�ssSti'.P�B
a'PLMWjMMwarAwm maracas wm
Construction Debris Disp6SdAffrdavit
(required forall demolition andrenovation work]
In accordance with die shah edition of the State&19&g Code, 780 WX Section 111.5 MWX
and die prowsbns of INGL o00,S S4; Bafldfrlg Pwn* l 1s rssued with the
conditn that the debris resufthAg from this work shad be disposed of 1.a properly rweenwd
waste deposit facility as defined by MGL c 111,S 156&
The debris will be transported by:
.Nn
(name of hauler)
The debris will be disposed of In:
(name of fadlfty)
(address of fadlity)
Signature of applicant
Date
• \ The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / // Please Print Legibly
Business/Organization N/amf eta:t n eml- l o
Address: �0lI// I cc ���`` /
City/State/Zip: O (� m A e �3 Phone#: �7p _ C)6 -3a 6 V
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers'comp. insurance required]* 11.❑ Health Care
4.❑ ,We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.❑ Other
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corpomtc officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
lain an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
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 certi under the pains an er l ' rlury that the information provided above is true and correct.
Signature: W W 2:� 2=7 Date:
Phone#: 7P —ofbd 3d6
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. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.inass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15