17 WOODSIDE STREET- BPA 16-269 PORCH ROOF RPR 1106 Main Street,Suite 106
Brockton,MA 02301
Aq Phone:774-381-7166
t a Fax:774-381-7165
f - Cal.:508498-8237
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CL� EPNINO SERVICES .._ _.
President
into@highlevelcleaningservims.wm
highlevelceaningwrw s@gmail.wm
RECEIVED
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OR
Massachusetts State Building Code, 780 Coo
MR jU�b N p 2�AU�
Rrvrsed.Nun 2016
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For 0IMial Use Only
Building Permit Number:' Date Applied:
-Building Otrrcial(Print Name). .. Signature: '. Date
SECTION l:SITE INFORMATION,
L1 perty ddre s: J1.2 Assessors Alop di Parcel Numbers
f1 c� t9 �tI.1a Is this an accepted street?yes nop Nuinber Parcel Number
1.3 Zoning Inrormation: Property Dimensions.ZoningDistrict � ProposedUse - Arm(sq 11) - Frontage(it) - -.
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard'
Rcquiied Provided Required Pro vided 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? Munici p al O On site disposal s stem 0
Public 0 Private 0. Check if esO P. Y
SECT[ON2. PROPERTY0$VNERSHlPit-
.NN ffnc Pant) �( /_ Ciryc�Stare,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK°(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ 1 Repairs(s) 0 Alteration(s) ❑ Addition 0
Demolition 0 Accessory Bldg.0 Number of Units_ Other O Speedy:
Brief Description of Proposed.Work=:. ` 6-7
uir [S w !CI c
ji
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Of citl Use Only
Labor and Materials) -
I Building S I. Building Permit Fee:S Indicate how fee is determined:
Cl Standard City/Town Application Fee
2. Ml trical S ❑Total Project Cost+(item 6)x multiplier x
J. Plumbing S 2V Qthei Fees: S
4.M1lechanical (tIVAC) S List: �
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:
x 6.Total Project Cost: .S a �s� 0 Paid in Full ❑Outstanding Balance Due:
IMA, uoo 3 j?o
SECTIONS: CONSTRUCTION SERVICES
fi r5J.'Construction Supervisor icense(CSL)
( � License Number Expiration Date-
Nante of SL Holder qy List CSL Type(see below)
/)O d ,v.nG S 1 _ Type, - - . Description ..
No.:md Street - U Unrestricted(Buildings tip-to 35,000 cu. ft.
oC+to R Restricted 1i32 Family Dwellin
Cityfrown,State,ZIP M 'Masomy
RC Raclin Covering
W3 Window and Sidinx
'I SF Solid Fuel Burning Appliances
A MI G blkv c e 1 Insulation
Telephone Email address F; D Demolition -
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.mid Street - Email address
City/Town, State ZIP Tele hone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M,G.L c.152§ 2$C(6)p,
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Iseuance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION lac OWNER AUTHORIZATION:TO BE COMPLETED.WHEN',
"
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERI ORAUTHORIZED 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.
Print Owner's or Authorized Agent's Nano(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 Contrnctor(HIC)Program);will a have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other Important information on t—eiiCYrogram can a faun 3C-
w,vw max,un:'oca Information on the Construction Supervisor License can be found at www.mass.��ovldos .
2. When substantial work is planned,provide the information below:
'total floor area(sq. f.) N (including garage,finished basement/attics,decks or porch)
Gross living area(sq. it.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'rype of heating system Number of decks/porches
"rype of cooling system Enclosed Open
3. 'Total Project Square Footage"may be substinacd tar"Total Project Cost"
CITY OF SALEg MASSACHm m
BEnDnQGDEPAR mew
120 Wil9FEIYGTCNS7MT,3IDR.CM
7kL(978)745.9595,
KII PAY(978)740.9846
vJBERLEYDRISOOl.L
MAYOR TrIOAMAS ST.PIEM
DIRECTOR cFPtmucPxomm/Bta=YGamnmomm
Construction Debris Disposa/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 c40, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a property licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
)o ,C,Z
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Y
Signature of applicant
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The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,lblA 02114-2017
www massgov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FU"WITH THE PERMITTING AUTHORITY.
Applicant Information Plesse Print Leelbly
Name(Business/Orgaffmtion/lndividuai): r
Address:_ J)V/y
City/State/Zip: S,,V Phone#: 3 j
Are you an employer?Check the appropriate box:
Type of project(required):
I.[Efram a employer with eagrbyees(fall and/or part-time).•
7. ❑New construction
2.Q I am a sole proprietor or partnership and have no employees working for me in 8.any capacity.[No workers'"comp.insurance required.] 9. El Demolition
❑Remodeling
3.❑I era a homeowner doing all work myself.(No workers'comp.insurance required.]t 10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I son a general cmdmctor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These subcontractors have employees and have workers'comp.insuramm'
6.❑We are a corporation and its officers have exercised their right of exemption par MOL c. 14'❑Other
152,§1(4),and we have no employees.[No workers'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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If The sub=contractors have employees,they must provide their workers'comp.policy number.
lam an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. \
Insurance Company Name: , J re, , Ce.
Policy#or Self-ins.Lic.#: Zn(.16 Expiration Date:
Job Site Address: I -,?� Lu v o C1 5 t XZ 5 City/State/Zip: V-,%.
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penaltles ofperjury that the information provided above is true and correct.
Sipilature: ��v wr.e .� S Date' -03�2+i�
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 M