26 FOREST AVE - BUILDING INSPECTION (i (hUL_TI F(kM 1 3g S cK Sol
Che Commonwealth of Massachusetts REC VED
3 Board of Building Regulations and Standards INSpECT10(j t gcYlfJ€S
780 CMR $ALEIvI
Massachusetts State Building Code, Revi J
pr
i
LO Building Permit Application To Construct, Repair, Renovate Or DeflVji
3 1`� 2 '
^ I One-or Avo-Family Dive/ling
N This Section For Oficial Use Onl
Building Permit Number. Date lied'
U)
(t DuilJing Olticiol(Print Name) Signature" Date
SECTION L•SITE INEORMATIUM
L1 Properrty Addr s t1 AssessoAssessorsMap.4r Parcel Numbers
Pf� tyAdd Av
I.1a Is this an acce ted streetl yes no Map Number Parcel Number
IJ Zoning Information: IA Property Dimenslons:
Zoning District - Proposed Use Lot Area(sq R) Frontage(R).
1.5 Building Setbacks(R) .
Front Yard.. Side Yards - Rear Yard
Required Provided Required Provided Requited' Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information' 1.8 Sewage Disposal System:
Public® Private O. Zone: Outside Flood Zone? Municipal III On site disposal system- O
Cheddf esO
SECTION Z: PROPIERTY OWNE ' Mile
.�1 Ownert of Record:
` c rY1 Qs11s�. �u va\t•C'� lM iA .2112 2S
N�mc(Print) City,State,ZIP
�6rwC,CQ
No.and Street Telephone 'mail Ad resp
SECTICIN 3: DESCRIPTION OF PROPOSED WORK;(check all that apply)`
New Construction O Existing Building Owner Occupied O Repairs(s) 91. 1Alterations) Addition O
Demolition O 1 Accessory Bldg.O . I Number of Units 3 Other 0 Specify:
Brief Description of Proposed Work":
%ne \ n�r�c•l ei(`
SECTION a:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: O/llc(al Use Only
Item Labor and Materials - -
1.Building S 15-0170 I. Building Permit Fee:S Indicate how fee is determined:
O Standard Chy/Town Application Fee
2.ElectricalV55,W0
❑Total Project Cost'(item 6)x multiplier x
3. PlumbingP Qther Fees: S
4.Mechanical (HVList:
5.i\lechanical (FirTotal All Fees:SSu ressiun) Check No. Check Amount: Cash Amount:
6. Total Project p Paid in Full ❑Outstanding balance Due:
� r-NI
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS. 137S*7 9 (7 I to
c.S '0`7 2 3 License Number Expiration Date
Name of CSL Holder
List CSL Type(sen below)
Typg - -. Description .
Ne.and Street
` U Unrestricted(Buildings upi to 35,000 cu. 11.
R Restricted 1&2 FamilyDwelling
Cityrrown,State,ZIP M IMasonry
RC RootWindow
covering
Sin
WS Window onJ SiJin
SF Solid Fuel Burning Appliances
Gcg q9(„1 !, w.+\C1 (+tJ V- X� Q\ 1�IN— 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) \-T�`O q
HIC Registration Number Expiration Date
HIC Company Name or IIIC Registrant Nam
\ �. 1.+c 2cC1rc C xt
N a td Street M Iq a19�Z q7R Spa 99 6 0 Email address
1t Q'C
Ci !Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G,L.e.152.§2SC(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 Isluance of the building permit,
Signed Affidavit Attached? Yes .........� No...........O
.
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETEDWHEN,
,
O�YNEit S AGENT OR CONTRA C1ORAPPLIES FON 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.
Is
Print Owner's Name(Electronic Signature) Dote
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my name below,l 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 Name(Electronic Signmo 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 Inprovement Contractor(HIC)Program)i will n have access to the arbitration
program or guaranty, fund under M.G.L.-c. 1d2A.Other impormnf information onlhe HICl'rogram can be-found—at— —
www.m:tss.eoe'oca Information on the Construction Supervisor License can be found at ww+v.mass.aov;Jos
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. ft.) 900 `x (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count y
Number of fireplaces Member of bedrooms 2—
Number of bathrooms
Numberofbathrooms Number of half/baths
Type of heating system FW J Number of decks/porches-k
'rype of cooling system Enclosed Open X
1. "rural Project Square Footage"may be substituted 1'or"Total Project Cost"
' The Commonwe N ofMassaehns m
Deparmiirenl oflirdttshWAecidents
1 Congress S7o'eer,Suite 100
Boston,AL4 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit Builders/Contractors/Elechiciaas/Plombers.
TO BE FH.ED WITH THE PERIYD7TJNG ADTHORI7T.
ApnllcautlafoWstion Plan rift Iaibly
Name(Business/Orgamrstiowbaviduel): I k:,Qyao,, 1 \/22"JVk-�
Address: r7 Sc �.�ci�Ce Gcc\ c
City/State/Zip:�w��1 �nO\ l Rhone#: q7$ • 500, 9
Any"an empbyer?Cbeck thewmprNte boa: ... of ro red
TyR P 1 .,ett(mai � ):.
1.Q l am a employer Wi& emPloym(foil aodkrP111vtM)• 7. ❑Ncw construction
2.®lama,eok rooapaMaship apd have no empbypeswort�g tarmem g; :fRl�pde]ng -
MYeagdty lNo imlrms'Damp.5a4oaoee mryoed) Ute•
9: 0 Demolition
3.❑Iam a homeownerdo�e0 work myaell:(No vrorkme'camp.iasmaox teq�ored.)t
Ejl mahmneownermdwIDhehbftconUaam tocmdMaflwakm loOBUl7dmge 1716A.
4. -
mr pmperry. I w,ll
eosme Natal]eonoutms eiterhaw wakes'compemmon rosu orsre sole. 11.0 Electrical repairs or additioms
popietpu WiNnosaoployces. 12.j]Plnmbmg'tepeus oiedditi 's .
5.0 ram a geaeml eon and I hs himd Ne soli amuaame lifted oo the agerbedehailL `
7bresobcontreatoahareemooyow and have wb�as'comp maneooct l3• Roofrepays
6.0Weareacorporshm.11 dilsofficroshaveeaexisedlheirsigWofea pvM(il.c. 14.Qthher- _
]S2,I7(4�md welasssa eaaployeea.'1No wakere'eampmsm:mferWueed)'., . - -
•anyWVC2fftikt dMOF has til muttabo foam tbeaecdoo Wowahowhigibetr vamkeis pohry •- -
t Homeowners rho anEauit Nis+�d%ntBNrY art doing ail evork�thmhae outride moat§olaoa a iiew af6devit sue6:
tContrscbla Naz theft this koi most mtfehedan-addiuw,al etieCebowmg�mmeoTau wbcoasaodsrote wlieNeroi aof those eootid kve
C1WGY— 9&ewb•rR sbere.=ADYa4!&y—unE! td—Waske!Co—P•PAY .
lam gn ewployer thatisyrovitTipg morkers'Cot"Pe n insgrm�cefor m�esrplgyees Bdowur thepe&7 and/ob sire-
informadom
Insurance Company Name:
Policy#or Self-ms.Lic.4/ Expiation Date:
Job Site Address: City x
Attach a copy of the workers'compensation policy declaration page(showingthe policy number and aspiration date).
Failure to segue coverage as required under lyldL c. 152,§25A is a criminal violation punishable by aline up to$1,500.00
end/or ono-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250.00 a
day against the vioLitoi.A copy of this statement may be forweided to the Office of hi DIA far imweaoe
coverage verification. '
Ido hereby certify under tbepains and penalties ofperjary that the fnfonnaden provided above is bee and correct
Date•
Phone#
OJjirW ase only. Do not write in this arca,to be coarplered by city er town o,BieiuL
City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
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 in 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 tbae*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 presorted 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 sub-contractor(s)narne(s),addmss(es)and phone number(s)along with their certificatc(s)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 lime.
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/hcense number which will be used as a reference number. In addition,an applicant
that must submit multiple pemat/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to tie
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be frilled out each
year.Where a home owner or titian is obtaining a license or permit not related to any business or commercial venture
(i.e,a dqg 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,Suite 100
Boston,MA 02114-2017.
Tel. #617-727-4900 ext. 7406 or 1-877-NUSSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CrTYOF SALEA AWSAC HUSETTS
B[a.DmDEPAR7mw
120 TAMIG7MSMET,3RDA)CM
Thi(978)745-9595
FAX(978)740.9846
RIIvJBERLEYDRIS�LL
MAYOR TkCMMS ST.PMM
DIREc►bxcFrwmcrxoYzm1BCaDm axamsiomR
Construction Debris Disposal 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 c4O, S 54; Building Permit 8 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
Miq
(address of facility)
Signature of applicant
Date