15 WOODSIDE ST - BUILDING INSPECTION (4) IL oo
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
qf/ Massachusetts State Building Code, 780 CNIR SALENI
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Ahir?011
One-or Two-Family D!velling
Building Permit
This Section For Official Use Only
Number.
Date Applied: /,_ c - l
ti?h121LY'W��f'r �
Dwldmg 0 h al(Print Name), �—
Sign
Date
LI Property Address:
SECTION I:SITE INFORNIAVON - -
J5 On.kIk rT 1.2 Assessors iNap&Parcel Numbers
I.1a Is this an accepted street? es
Y no_ Map Number Parcel Number
1,3 "Coning Information: L4 Property Dimensions:
Zoning D— istrict Proposed UaU
Lot Area(sq tt) Frontage(R)
L5 Building Setbacks(ft) .
Front Yard Site Yams
Provided Require Required Provide) Rear Yard
Required wired
y Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information:
Public❑ Private❑ Zone: _ Outside Flood Zone? 1.8 Sewage Disposal System:
Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP!
2.1 Owner'of Record;
N YMe!1❑mf
�S � aty state,zIP
gf
Nu. m!J S(rccl
elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner•Occupied Repairs(s) p Altemtion(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units
Brief Description of Proposed \V ork= Other ❑ Specity:
: ° r aor ll
�r•'Y�VMG rGtnj/t ) SL{w-e. D),.�/O 4 rvLt P�n�t ' Re Pace
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building S 6.0 60 I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical 5 00 ❑Standard Ci
.w tyllown Application Fee
3. Plumbing S ❑Total Project Costs(Item 6)x multiplier x
2. Other Fees: $
4. blcchm!iwl (IIVr1C) $ List:
.5. \fechanical (Fire
Su ression) S
Total All Fees:S
6. Total Project Cttst 'S / Check No. Cher —Cash Amount
6� .00 ❑Paid in Full ❑Outstanding Balance Due:
1T - gI05
M A--
SECTION 5: CONS"fRUC'r1ON SERVICES
5.1 Construction Supervisor License(CSL) r � Es imtion ate
License Number P
arridr)
Nanw of SL Holder List CSL'fyp e see below)
W, Sur Type - , Description
No.and Street U
;
Unra;trmleS Buildin s u to 35,000 cu. IlJ
R ResUicted 1&2 Famil Dwellin
t M Mason
tty&fnu,State,LIP RC Rootin Covering
WS Window and Sidi,
SF Solid Fuel Burning Appliances
n. !'norT'SQAlP�''o �h l Insulation
9� 7 6V dJ .
U Demolition
Email address
'I'cle hone 3q2�
5.2 Registered dome Improvement Contractor(�lll� 111C Registration Number Expiration Date
1,11 ,Company Nanic or HiC Reg Uant Name J McYy�Sa Tr-�
Email address
No.a 1,aid Street U ,-Se`,4-Q�°(�.
t Tel--/-- .
Ci lTuN ,State, IP
SECTION 6:WORKERS'C06IPENSA I ION INSURANCE AFFIDAVIT(M.0 G C. 152.§ 25C(�)
pleted and sue mniued with this application. Failure to provide
Workers Compensation Insurance affidavit must be com
this affidavit will result in the denial of the Is�uance of the building
Signed Affidavit Attached? Yes ..........
Cl No.......
SECTION 7a:OWNER AUTHORIZATION TO BE.CONIPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
1,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.
Date
Print Owner's Name(Electronic Signature)
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.
Date
Print Owner's or Authorized rlgent's Name(Electronic Signature)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an`own'I n r who hires
as tunre a tend contractor
(not registered in the Home Improvement Contractor(HIC)program),
program or guaranty fund under M.G.L.C. Id2A.Other important information on the HIC Program can be fount at
www.mass.��ov;'o.a Information on the Construction Supervisor License can be found at www' miss "uv''Jns
__--� —
2. When substantial work is planned,provide the information iuing garage finished basement/attics,
decks or porch)
'fotal fluor area(Sq. ftJ Habitable room count
Gross living area(sq. ft.) Number of bedrooms
Number of fireplaces Number ofhalflbaths
Number of bathrooms Number of decks/porches _ _—
'type of heating system Enclosed�.—Open
"type of waling system
Foorrge"may be substituted for"'road Project Cost"
3. "'rota! Project Square
L Massachusetts.Department of Public Safety
`b- Board of Building Regulations and Standards
CLicense:nn Superri9
License:CS-098469
GARY P MORRISON
13 VANDSOR PW '¢ r
BEVERLY MA Of915�
Expiration
Comm,ss,oner 05/0912014
Unrestricted-.Buildings of any use group which '
contain less than 35.000 cubic feet(991 in")of - -'
. encloscd space. i
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
FW DPS littming inlW.tion Milt: ..Mass.Gm/DPS
p
i
_ s
y
CITY OF Sivim,[, %L- SSACHUSE-FrS
t t E]UML\G DEPARME.NT
120 WASHLNGTON STREET, 3'°FLOOR
...�. .;� TEL (978) 745-9595
F-Cx(978) 740-9844
KIN tBE1tLEY DRISCOLL
��UYO:L TF(OJL�S ST.PIF_RItB
DIRECTOR of PuLIC PROPERTY/8CILDLYG CONNISSIONER
Construction Debris ;Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CDAR section t 11.5
Debris, acid the provisions of i'YIGL c 40, S 54;
Building Permit It 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 IGL c
t 11, S 150A.
The debris will be transported by:
ti hh \
y 6 orr77c)^ A'n.c�d 4%/tom/ �P.yr a tniy
(name 0f haVcr) �—
The debris will be disposed of in
(name of racdity)
(address or facility)
i
signature ofpermit applicant .— -
--
The Commonwealth of Massachusettstl?rinrrn
Department oflndustrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Awlicant Information Please Print Legibly
Name (Business/Organiration/Individuap: ,qO j
Address:
City/State/Zip: g Phone#:
Are y an employer?Check the a propriate box: Type of project(required):
1. I am a employer with_ z� 4. ❑ I am a general contractor and I
employees(full and/or part-time).
• have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp, insurance comp. insurance.:
9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: /��//s t,.eF�C¢Jls �y
Policy#or Self-ins.Lic.#:����'tJ(�l/l (—�/ Expiration Date:
Job Site Address: City/State/Zip: 5�46— HA TM
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 certify er the pttins-and penalties oflieriury that the information provided above is true and correct.
Si ature: Date
Phone#:
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. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: