0014-0016 HODGES COURT - BPA-16-1024 q40 C,tz t Ft
The Commonwealth of Massachusetts
Board of Building Regulations and Standards i�
Ts
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct,Repair,Renovate Or Demolish ajMfr 36
One-or T1vo-Family Dwelling
Tbi Simon For Oaial Use
Building P 1 :. �'
+ g )M(*-(Fred 4nine)
l -I (e SECTION i;$1"118�'llh'ORMATI ,
1.�ypertytddrf�ss:�a�ee 1.2 Assessors Map&Parcel Numbers
"' Map Number Parcel Number
Lla Is this an accepted street?yes_ no
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distrix 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 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: l.s Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system D
Public 0 Private 0 Check if esO
SECTION 2i P1tOPERTyOWNERSIIIPr
2.1 Owner'of/ ;Record:
�,% ,CAeAon 1/ RGn I/+/ Ii S/���if71 i �'`I/ft O/5-2,0
cA
Name(Print) City,State,ZIP
Mfr427f. VJ S% t//&f
No.and Street Telephone Email Address
SECTION 3:DESC APT OF PROPOSED WORIO(ebeclt 11 that apply)
New Construction 0 sting Building Owner-Occupied 0 Repairs(s) Alteration(s) O Addition 0
Demolition Accessory Bldg.0 Number of Units_ Other O Specify:
Brief Des nphon of Proposed Worle: -A-/
r w
SECTION 4:ESTIJL7ATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item abor and Materials
1.Building $ 60 O 1 Buikiing Perron Fce.$ Iidkate how fee is determined
o 13Standard Ctty/I"ownApplication Fee
2.Electrical $ �mca O Total Project Costr(Item 6)x multiplier —X-
3.Plumbing $ S"DOO 2: Other Fees:
< V
4.Mechanical (HVAC) $ 2(%)o0 List:—
5.Mechanical (Fire
$ Total All Fees:$
Su ession eck No. Check Amount: Cash Amount:
6.Total Project Cost: $ Yo 2yV 0 Paid in Full O O,utstand ing Balance Vue:
1 « C4A-�LE,0 4 V r
Sim-014 5: CONSTROMON SERVICES
5.1 Construction Supervisor License(CSL) C1._ OV
License Number Expiration Date
.r r Name of CSL Holder v
S List CSL Type(see below)
,?�A G2ote Sr2•ee�-
No.and Street T ..
? O RRestricted 1&2(Buildings
Dwelling 35,000 cu.ft.
aty/rown,State,ZIP' M I Masonry
RC xoom covecin
-� ` (/ WS window and Siding
�0 /oZQO �y6 Tc,4, xyeL0/,*� IF Insulation Solid I BurnmgAppliances
Telephone Email address D I Demolition c�.
5.2 Registered Rome Improvement Contractor(HIC) jG+3f 5•� _ / i7
✓&A P, Fix ty-e—y HIC Registration Number Expiration Date
HIC Company Name or HIC Registmnl Name
No.and Street Email address
Ci /fown State ZIP Tel hone
SECTMN 6:WORIERs,COpApENsATION NMRANCE AFFIDAVIT(3LG.L a 152.1251CM
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 pFIii building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTIXI3Y /s9 01W14R AUTHI'1RIZA T6 BE C6A01ZMJI WHEN
qWNEII'S ADW 4R CQCTOR FQR RMAING MM
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7h:OWNF-W OR AUTHORIZED AGENT DECLARATION
By entering my name below,I her y attest der the pains and penalties of perjitry that all of the information
conta'in'ed in this application is true d cc ate to the best of my kn ge and understanding.
r-htl ►t+Lue_t C�
Print Owner's or Authorized Agent's a(Electrfuric Si ) Date
NUT4vmt
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
Mny mass.eov/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 basement/attics,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"
The CommonweAM ojMgsspchuseM
Depar6nent oj1jultrstrrdlAceMmts
I CongressSare"4#000
B.osYo>'y Mid 02114-2017
www.massgov/dia
Workers'Compeandon h igunu ce Affidavit Bonders/CoMradora/Eloctddam/P)umbers.
TO BE FH.ED 87TH THEE PERPAiTm NG ADTHORIm
Name(Bossin s0*mizatioa/ln hi&mn:
Addmss: 'Zoll (TYCO Ue S T2
c5ty�sta zip: sw . wi�► o�7 o Phom
Type of pro ei(rtgairedj:
Areyoaaue QKk Wepppr#p #mbI m.- -
l.p I a employa wA (m psn->ina)•v 7. p NeW ounstn duo
1 amaeokpvopuxlw.RprmmaLiy!godLeveaoer�loypmTo�g fame in S. :pR,gMdeft
a�eipaelry'.(Nd wnrkae'"comp.le4emx mq�med.j , . � - 9: �Demolitiim'
pltanahaaieoamadokgan wodc myself.(No wmkaa emgr.tnsuwass I+ .lopBradingedditim,
4.13 I a.6omea.me and wffl be hirurg omaams to conduct ail wakm mypopeny. Iwo
easvedatancovftammaeiIha6aveMin s'compeatationmaaaoceoran:sok 11.pElectriealrepaitsoradditions
propaietmewffi aoamploym. . -:. l2 aradditic�s
Z7>fll®b>ng
S.plamageaemleakoaloraodlhevehaedaa:euh.romae�rinatedo>tdv: alnoi: 13. -Roof �,
7hgreasbo®beemmheveearpkyees and pavewmlaai'emp.idwaeaed _ - : .Q: rePaQe.
6.0WeaeacoaporatioaandinDffia haveciff iiiersismofeaemptkapamot 14.pO�er
137.51(4),cad weaavememployeea.pro wmlme'eomptawoaaa tegoiad). -
•Atryappnexrltat ...ilmap oho fiBomaeautfod hebwshow6igde(r pokey
t Homeown�vfiosuLaaif affda4iti they are all wofl` Fk aeahue autsrdeeariaatla3 mch
rCoaauaam do 4mkthis bmmust and6edmtid"oval shWWk6wmg ere c®Eofdom&ccdiasaaamd same whadmim mime a have .
employees.,ffffie, ...... have.®pl4yee41)KX>a�P�kk&eq-.wadmW-m W pobeym*o4 ; .
lam erg ewpJoyrr tha[ispm fdfng loorkerg'w Pm++allon fnsurmaejor my saes Belary Hrepoliry awd/ab 8ke -
tajoion.
Insurance Company Name:
Policy 4 or Self-ins.Lic:Ol Expaatiom Date:
Job Site Address: Cit03tatemp:
Attach a copy of the w'orker's'compensation policy declaration page(showing the policy number and erpirvilon date).
Fel7ure to Beane covasge as required under MGL c: 152,§25A is a cr�al vloLtion puarsbable 6y a fide up to El,s,00.00
and/ year imj ar,m m®;as Well as civil pensides m the form da STOP WORK ORDER and a fine of up to 3150.00 a
day lator..A copy of this sm mmt may be fofa'a ded to the Office of Investigations ofthe DIA f6r binv see
coverage ti
I do hereby tbepaws and penabies ojperJxry fhalahe mjormariox pnvs7ded &xe sad comma
Phone N,•
F
eoily IMao!rrrife tarhis meq fo be competedbyay ortowx oBldeL
wn: Permittisense d
thority(circle one):
f Health I Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Phrmbing Inspector
rson: Phone S:
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 penton in the service of another under any contract ofhim,
express or implied,oral or written."
An employer is defined as"an individual,partnership,aseaaetion,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 tnerein,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 commonweakh 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 fon the performance ofpubhc work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to The contracting suBrority."
Applicants —
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
nom',supply sub-camtractm(s)namc(a),address(es)and phone nurnber(s)slung with their crrtificau(s)of
insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LI.P)with no employees other then 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 es should enter their
self-insurance license number on the appropriate lime.
City or Town Officials
Please be sure that the affidavit is conwlete 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 aur to fill in the permit/ficemse number which will be used as a reference number. In addition,an applicant
that must submit multiple permiVlicenae applications in any given yea,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 ofthe 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 f inure permits or licenses. A new affidavit must be filled out earl
year.Where a home owner or citizen is obtaining a license or permit not Mated 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
Depatiment of Industrial Accidents
1 Congress Street, Suite 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
07'Y OF SALEA A ASSAaA SEM
Bu7DncDErAimmw
120 WA9MC7MS98EET,3ADFLOOR
7kL(978)745-9595.
FAx(978)740.9846
SIIvI6ERIBYDRiSQ7LL
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DmEcrcicCFAMUCPAM x Y/surra MMONU
Construction Debris Disposa/Affidavit
(required for all demolition and,renovation work)
In accordance with the sbcth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c+40, S 54; Building Permit 8 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.-
(name
y:(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
n tur o a
at