6-8 GREEN ST - BUILDING INSPECTION 4 p .
O � S
9 The Commonwealtb of Massachusetts
$- 011, J Board of Building Regulations and Standards SALEOFI Massachusetts State Building Code, 780 CMR
Revised Alar 101'l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
! This Section For.Official Use Only `
Building Permit Number: Date A" eds
-BuiiJing flfYcia/(Print Name). Stgnaturaf!^ D
SECTION 1;SITE INFORi IATION
I_I Prop sty Address: 1.2 Assessors blap dk Parcel Number
I.Ia Is this an aece ted street? es no Map Number Parcel Number
1.3 Zoning Into
1A Property Dimensions.
Zoning District Proposed Use Lot Area(sq tl) - Frontage(R)
L5 BuiidingSetbacks(ft)
Front Yard Side Yards Rear Yard
Required - ProvidedRe uiml Provided,
q Required vided"
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Systen:
Public❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On site dispoL system ❑
Check if 'eS❑
SECTION 2t PROPERTYOWNERSHIP!
2.I Owne44f A/
I�'�me(Print) G
� ly,State,Z7.t �p
v"p evy2n O�
Nl
Telephone
Email Address
SECTION 3:DESCRIPTION OF PROPOSED tVORK3(check alphat apply)
New Construction❑ Existing Building Cl I Owner-Occupied ❑ Repairs(s)101 Altenttion(s) 0 Addition❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
—, Brief Description of Proposed Work': Pto
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Hera Estimated Costs: Official Use Only
Labor and 4laterials)
I. Building Q0+00 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrird S ❑Standard Cily/7'ownApplication Fee
❑Total Project Cost`(item 6)x multiplier x
3.Plumbing S P PlIter Fees: S
4.Mechanical (1-IVAC) S List:
5.Mcchanic:d (Fire S
u ressiun) "Total All Fees:S
7A Check No. Check Amount: Cash Amount:
6.Ti tai Prr)ject Cost S t&7erQ ❑p;tid in Futt ❑Outstanding Balance Due:
M r�r i t gESD `� Z2 v—o l-1- C) ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructimi Supervisor License(CSL)
License Number Expiation Date ,
Name of CSL Holder
List CSL Type(see below)
No.and Street Type', Description
U I Unrestricted Buitdtn a zo 35 tiU(!cu.ft.
City/Town,State,ZIP R Restricted I F:unil Dwellin
M I Masleary
RC I Roofing Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
T I Initiation
Telephone Email address D I Demolition
5.2 Registered (tome Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.mid Street Email address
CI /Town State ZIP Telephone
SECTION 6:WORKER$'COMPENSATION IN5*IiICE AFFIDAVIT(M.G.fL c.152.§25C(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 Affidavit Attached? Yes ..........t] No...........❑
SECTION 7a;OWNER AUTHORIZATION TO BE COMPLETED WHEN.
OWNER'S AGENT bit 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 Nance(Electronic Signature) Data _
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all ]I
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 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 W have access to the arbitration
program or guaranty fund under LG L.p. Ia2A.Othcriroportant mfbim–a ion onihe'ri[C-Proj(ramcan l of Tat–
ixww-mass.eov;'oea Information on the Construction Supervisor License can be found at AA&A Prov='dpi
2. When substantial work is punned,provide the information below:
Total floor area(sq. ft.) 'r (including garage,finished basemeuVattics,deck7or orch)
Gross living area(sq.it.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalf/baths
"type of heating system Number of decks/porches
rype orcooling system Enclosed Open
3. "rotal Project Square Footage"may be substituted tor—Total Project Cost"
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Construction Debris Disposa/Affidin t
(required for all demolition and.renovation workj
In accordance with the sbM edition of the State Buckling code, 780 CMR, Sectmn 111-S Debris;
and the provisions of MGL coo,S 54; Buildine Permit B is issued with the
condition brat the debris resulting from this worts shah be disposed of In a properiy licensed
waste deposh Wity as defined by MGL c 111,S 150A.
The debris will be transported by:
(name of tiler)
The debris will be disposed of in:
(name of facility)
-
(address of facility)
Signature of applicant
�' Date
The Commonweafth ofMassachuseGtr
Department oflndustrWrAccddenty
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
"Workers'Compensation Insurance Affidavit:BWWerdContmctorsWectridans&lumbers.
TO BE 1`11"WITH THE PERMTTIMG AUTHORITY.
Applicant Information Please PdNt Leelbly
.Name(Basiness/organirationftitividaa2):
Address: Y/�za&" A(
City/State/Zip: M6 0 Phone#: r�7Z) 91�p — M/Z
Are yon are employer?Check the approprlata bur. Type of project(regalred):
1.01 ea}a emloyp'with s"loyees(full and/orpant-time).• 7. ❑New construction
2. a v a sptolaopnetw w pwuaahipmdhm m employm vmkmg f re cot m S. Q 12emodeling
any caPacib.[No workes'comp.roan
mce required]
3.Q 1 am a homeownerdoimg as wwk myself fNo workers'cmp.insmamce required.)t 4. 0 DeMDhtion
4.Q l am a homeovrne and wgl be$'king cmvactms to conduct all work m my popery, [will 10 Q Building addition
eavure that all contractors either have workers'compensation msmance w are sole 11.0 Electrical repairs or additions
prop worra with no employees.
5.0 1 am a sanml comaaw and l have hired the sub�cmmmcton limit on the attached sleet 22. Plumbing repairs o1 additions
n esc sub cmtracroshaw employees and bans workm'comp,maenance.n 13.01loofrepanrs
6.Q We are a corporation and its oticas have eswc6edtheir right of exemption pe MGL a 14.2V 'tither d/
152,§1(41and m bake m rmployees.[No workers'comp.k s regrmed.)
*Any a}plicmd this checks box#1 must also fig out the sooimbelow showIDg tkem worker'=mpmsmm policy information.
t Homeowmss who submit this atidwit mdicmurg they arc doing all work and new hire outride comm"ora mans submit a crew afir am indicating seek.
tConautors that check this box must aaachedan additional shoes showing the mane ofthesub-emmauiws sedsmte whether"set those mtiries have
aWkiyees. Ifthe sub=contraaurs have employees,they must provide rev workers'comp.policy number
I am an employer thatis providing workers'eompensatison insuranaefor my employees. Below is thepolfey,andjob site
Information.
Insurance Company Name:
Policy#or Self-ins.Lic.M C15 p— 1 � 90�—
Expiration Date: (`1 '20 Z (r7
lob Site Address: to 6 2,-e0^ Y( Citymmemp: da' e 7 7 0
Attach a copy of the workers'cosepensatlon policy detdaradon page(showing the policy comber and i6piration date).
Failure to secure coverage as required under MGL c. 152,§25A is a critnmal violation punishable by a fine up to$1,500.00
and(or one-year imprisornrrat,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 insenance
coverage verification.
I do hereby certify under bepaitu and aures ofperjwy thm fire information provided above is true and corroct
Si 8 t�
Phone M, E
O,BwW use only. Do not write in this area,to be completed by dry or town o,04eW
City or Town: PermitlUcense#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.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 aooriayer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more then three apartments and who resides therein,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 errgrloyment 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 drainer 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}resented to the contracting audnmity."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addresses)and phone number(s)along with their certificate(s)of
insurance. Limited liability Companies(11k)or Lirr ited 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 pemrit/liceme number which will be used as a reference number. In addition,an applicant
that must subunit multiple perm vbccose applications in any giver 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 the
applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venire
(i.e.a dog license or permit to bun 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
I Congress Street,State 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
j Massachusetts Department of Public Safety
Board of Building Regulations and Standards
i License: CS-109965
Construction Supervisor
MATTHEW KEANE`
414 LAFAYETTE STRE TrI
SALEMMA 07920 ":3 4 M-
• V6 .,
r'jzuz LA...— Expiration:
Commissioner 0110912020