31-33 CEDAR ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
�N Massachusetts State Building Code, 780 CMR S`Q'L
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a C--c F-/I en
One-or Two-Family Dwelling ECT p,- nh
This Section For Official Use Only.
Building Permit Number: Date A hed: �S
„(1 Building Official(Print Name) Signature. _ Date
�— SECTION 1: SITE INFORMATION
J1. Prop Address: 1.2 Assessors Map &Parcel Numbers
if — C c�✓ 7�Ce
L la Is this an accepted street?yes no Map Number Parcel Number
1.3 ning Information: 1.4 Property Dimensions:
sed ��
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) ,
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 ater upply: (NLG.L c.40,§54) 1.7 Flood Zane Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Twnrrt of ReS r%
St, t� f iis.� LVt lahl
Name(Pent � L>•f.{ City.State,ZIP
No.anStr fj Telephone Email ess />w f��th
SECTION 3: DESCRIPTION OF PROPOSED WORIe(check.all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Pjoposed Work'-: C. fZ 4 ` n o12r /
a
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 'a . p Q 1. Building Permit Fee. $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ Ot 00 0 ❑Total Project Cost'(Item 6).x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ f 0 List.
5. Mechanical (Fire
Suppression)
$ Total All Fees: $
(,.� Check No, Check Amount: Cash Amount'
6. Total Project Cost: $ l � 000
❑Paid in Full ❑Outstanding Balance Due:
m��LJOD -r-O -I- t-Aaq?_-0wtj ILI (-I
SECTION 5: CONSTRUCTION SERVICES
r 5.1 Construction Supervisor License(CSL)
CS-0`13706 i f
Yl �tq lZ ve License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
,7o6 0s re0 tom.
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted L&2 Family Dwel ' e
City/Town,State,ZIP
MSM,
RC Roofing Covering
WS Window and Siding
'rg / ,/ n �J `/� SF Solid Fuel Burning Appliances
Q2 9,?o 4j y i JcNj-nit _//q",C'l I Insulation
Telephone Email address ll Demolition
5.22 Registered Home Improvement Contractor(HIC) 531 9 9 /Y//
1 e Awgyey HI253199 —
Registration Number Expiration Date
HJjC Company Name or HIC Registrant Names
i�e
No.and StreetEmail address
City/Town, State,ZIP Telephone
SECTION 4170RKER5' COMPENSATION INSURANCE AFFIDAVIT(ALQL.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be ompleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Iss e of the building permit.
Signed Affidavit Attached? Yes .......... No ...... ❑
SECTION lac OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR-BUH DING PERMIT
I; as Owner of the sub' ct property,hereby authorize
to act on my behalf, ' matterl relative to work authorized by this building permit application.
Punt er s Name ec me ignature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
Bye g my name below, I hereby attest under the pains and penalties of perjury that all of the information
co d in this pplication is true and accurate to the best of my knowledge and understanding.
&�
t caner s or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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(HIC)Program),will not 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below.
Total floor area(sq. ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
ti a
J i CITY OF S.U.E:N I, KXSSACHUSETTS
BL'IIDLNG DEPARTMENT
• 130 WASHDZGTON STREET,3m FLOOR
°j TEL (978) 745-9595
FA.Y(978) 740-9846
IcL%iBER EY DRISCOLL
NIAYOR THOMAS ST.PMM
DIRECTOR OF PUBLIC PROPERTY/BUILDDIG COJL%=IONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information T X(
p a` / Please Print Legibly
NaMe (Busimx OrWiilzatiorvimiividual): c�kl X(Alf Vt--/� L
Address: 20 k'7 lCz g0t,,-e ST20Z'-t° / q
City/State/Zip: Phone fl: !7f �p-6 A y y
Are you an employer?Check the appropriate box: Type project(required):
1.❑ 1 am a - oyer with 4. ❑ I am a general contractor and I 6.- New construction
et oyees(full and/or part-time).• have hired the soh-contractors
2. am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have tto employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. C]Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12,0 Roof repairs
insurance required.)t employees. [No workers' 13.0 Other
comp. insurance required.]
•Any aPPlicwd that checks box#I must also rill out the x tion below showing their wwkas'a mnli nation policy mromutioa.
'I fnmeowmts who submit this aridavn indicating they ate doing all work and then hire outside contraction must submit a now affidavit indicting such.
:Comrm.7om that check tbis box in=anachod an additional shoei showing the name of the sub-contractors and their wotkas'comp.policy inra maaion.
I am an employer that is providing workers'compensation insurance for my employeex Below is the Palley andJab stte
information.
Insurance Company Name:
Policy 4 or Self-ins.Lie.M Expiration Date,
Job Site Address: City/StatdZip:
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 53,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S '0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigutiof the DIA for insurance coverage verification.
I do hereby i nde he ins and penalties of rjury that the information provided above' true and correct
Si gna t vex Data:
Phone#: CI-)I 0
OKIc4d use only. Do not write in this areq to be completed by city of town official
City or Town: Permit(License# __
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: __ Phone#.