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35 WINTER ISLAND RD - BUILDING INSPECTION (3) j� The Commonwealth of Massachusetts U L Board of Building Regulations and Standards Town of 1 Massachusetts State Building Code, 780 CMR, Ta edition �t� Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Ttco-Famih Dwelling This Section For Official Use Only Building Permit N bet: Date Applied: Signature: o Building Commissioner/ spector of Buildings Date SftJTlOf4 1. JITEXNFORMATION 1.1 Property Address: ssessors Map& Parcel Numbers I.I a Is this an accepted street. es Map Number Parcel Number I.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(tt) LS Building Setbacks(it) Front Yard Side Yards Rev Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone?. Municipal❑ On site disposal system ❑ Check if vcsC3 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 'o1 r� fLA[4tttE�b�l or- �t`� Name(Prim) Address for Service: (114 �4 Signature Telepho try SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) WJ Alteration(s) ❑ Addition ❑ Je13ition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: escription of Proposed Work': 4�y e+ f P2PL.�+r SSs.D� �S7R-,�y SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Labor and Malerials ing f �jD'— I. Building Permit Fee: f Indicate how fee is determined: ical S ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x ing f 2. Other Fees: S anical (HVAC) S List: nical (Fire Sion Total All Fees: f Check No. Check Amount: Cash Amount:6. ota Project Cost: S 0 Paid in Full Cl Outstanding Balance Due: s SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) . l©'Iy S License Number apoauon Date N.4mc r Lin CSL g02 t is y rs .�. T,�f . ype(,cc below) 1� v �Y t.e tv1� T Description Address U Unrestricted(up to 15,000 Cu. Ft.) R Restricted 1,12 Family Dwellm S na ure M Masonry Only RC Residential Roofirill Covering Telephone WS Residential Window and Siding SF I Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.125C(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 AfftdavilAttached? Yes.......... 0 No........... 0 SECTION 7a: 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. Si nature of Owner Date SECTION 7b:OWN ERt OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the pains and penalties ofperjury) NOTES: ri. An—O—wner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor t registered in the Home Improvement Contractor(HIC)Program),will MW have access to the arbitration gram or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and nstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively. en substantial work is planned,provide the information below: oors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch) ving area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfbaths Tvpe of heating system Number of decks/ porches Ty pe of cooling system Enclosed Open 3. "Total Project Square Footage'may he substituted for 'Total Project Cost" CITY OF SALLM PUBLIC PROPRERTY DEPARTMENT L: g la l; ,".1,.:11 tON)1I %I. III '1'3.'J;. I, '; I %\ ';'.V 'J. '"le Construction Debris Disposal Affida-it (required l6r all demolition and renovation work) In accordance %%ith the sixth edition of the State Building Code, 780 CNIR section 1 1 1 5 Dcbris, and the provisions of'vIGL c 40, S 54; Building Permit H is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal hcility as defined by MGL c I 11. S 150A. The debris will be tr:utsported by: (1 ' me of haldrr) I he debris will be disposed of in (nJ1nr ul IJc filly) I Jddre.. of l�rdnV) �I LIIJILLIc "t I)"11111 .11)I11KJIn JIC CITY OF S.1LE%1, .L-kSSACHLSETTS 13L'BDING DEPARTSIL'SiT 120 WASHINGTON STREET )eO FLOOR TEL (971) 74S-9595 FAX(978) 740.9&9 KI.N[BERIEY DRISCOLL �AYOA I110t+tAS ST.P�RRa DIRECTOR OF PLBLIC PROPERTY/BU DLNG C0\L%BSSIO%ER Workers' Compensation Insurance AMclavit: Builders/Contractors/Electricians/Plumbers Applicant Information D n Please Print Legibly Nalne (Businev OrWizanomindiv1,,du l): Address: City/State/Zip: fi?!� Phone #- Are you as employer?Cheek the appropriate boa: Ty pe of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction �tnployees(full and/or pan b -time).• have hired the sub-contractors 2. 1 atn a sole proprietor or partner- listed on the attached sheet : ?- � Remodeling ship and have no employees These sub-contractors have S. Demolition working for mein any capacity. worker'comp.insurance. 9, ❑ Building addition l No workers comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions J.❑ 1 am a homeowner doing all work right or exemption per MGL 11.0 Plumbing repairs or additions myself[No workers'comp. c. 152.§1(4),and we have no 12.❑ Roof repairs insurance required.) t employees. two workers' 13.0 Other comp. insurance required.) -Any applicant thus chocks 1001101 MUM alw fill sal the saeriea below showiest their workers'carnpeasadm policy infumunon. 'I In(ncownen who subedit this affidavit indicating they an doing all work and has him amide eoormeeon mush submit a row afthlsvil indioring suck {,mtravton thal check(his box must attached an addiriwd shore.hawing the tome of rM soh-contrackn and their wurkus'comp,policy infsxmatias l um an employer that Is providing workers'rompetsradon lnsaranee jar my employees, Below/s the pas/lry and job slat information. Insurance Company 'Jame: Policy 4 or Self-its. Lie.p: Expiration Date: Job Site Address: City/Stawzip: Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to sec ge as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to ,500.00 an r one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of up m S_ 0.00 a day a insa the violator. Ile advised that a copy of this statement may be forwarded to the Office of Invcaligat iu f dte DI for insurance coverage verification. 1,10 hereby ce the pains and penalties of perjury that the information provided Ubo a is true and caneca Ja �zIr T I Ir Phorc 4' 2 gi !� iDfrial use unfy. Donor write in this area, to be completed by city or town afflrimi iCity or fawn: __ __ Pcrmit/Llcense/ I.suing Aulhorily (circle one): j I. hoard of Ilrullh 2. Ruilding Department ]. City/rownC'lerk 4. Electrical Impcctor 5. Plumbing Inspector 6, Other (_„(dace Person: _ __. _.. Phone It'