20 JUNIPER AVE - BUILDING INSPECTION . ... .. . ..
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)1 Massachusetts State Hwldmg Cade 78q CMR 7 edtuon
4-
USE
�6Butldmg Petmtt Application To Construct Repatr Renovate Or Demolish u+ R�r nc:d lnnum t .
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Dae Applied
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Stgnuture
Date
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10 --l.-;slTW;lNFOltMA 0 ' -
1 1'Property Address 12 Assessorsj qp
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Dimeosiorec
Zoning Dutnct �" Purposed TW Am R 41 f.
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Required Pin"vrded
'Regtifned Provided.: Re'q j
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16'.Water Supply
(MAIX 6.40,j 54):; 17 Flood;Zane Information 1 S
Sewage:Disposal System
Public 1 - M
Private
PMunicipal On siie disposal system ❑
b yes
17
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PROPOSEOM ..
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Demolition ❑ esRry .... uIn
f Pr�60.biiidW&Vi 32 MIN
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Estimated...........
nlcw,u*se Only
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okmale"flais
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BuildingL.%, Peru Fee v
pl. -
haw fee rs determined
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Amount
6 Total Project Cost
(2Outstanding I c
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..............
S
TIONSERVICE
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RKERSt COMPENSATION;INSURANCE AMDAVIT, Z;Uc_452 §;25' C(Q)
7
compacted j and ibinittid' Failure Oftivi
flus affidavit will nesulf to the denial of the lssunnce ofWorkers
utldmttierbermu
Signed'Affidavit AttachedT
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SECTIONR7ANTO`BE;C-OMPL-VrEWWHEN'.'!OMq4ERiAUTHORIZA.TIO
VORVONT A`CTOW, -PPLIM"
OWNER'S-AGENT FOR`BUILDtNG PERMIT
� j ` .� ���: ,as Owner of the subject property hereby
er
relative
0 utfforJZW by thisbUilaapphcahon ............
gAc_T_
GlNT.,.DEC4*RA,,.IdN-1.
. .......er or`Authorized Agent Hereby declare
..
�s Ifid'ififfiffiiatiowdh,the, omgoing app ica u
on WrAmean � alwateto the best of my knowledge and
be
�,j'
Sigiiiiiak of Owner&:'M
tho Agan[
. . Si ed tintler.tlie' mhs'arid t eso perjury
. Owner who
'obtains....W....u..
.....
inV..perm
to, dhis/her OWWWO
or owner who-tures'anunregistered brthctor
(notegisfiRildnIfiCGMImprovement-Contract&(HIC)lProgram)
.%
".> Canstructton Supervisor licensing(CSL)can 6e Faundm`780,CMR Regulauoiis J l0 R6 and 1 LO RS' respectively-
aftitiabelow ...........
iftt .......
in:
"diage,ifinished;b'mmen a im,finks-or pt
Total floors urea q
f
........ ..... Gross Iwmg.area(Sq .FC)
Flabitab)e
Number of fire laces Number
OOMS
0 10
bathroomsNumber of
systemType of heating .........
Number.of V.;
ScUfor,MF W 5,u stitut -7'T and
on -.
..........
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6�x
�AA E `VS" �i-81...L'.ib1y 5�14.akSSACL14�SETrSBUILDLNG DBPiRT\mNT
120 W.isxLNGTOtd STREET, 3' FLoolt
TO— (978)755-9595
F.ax(978) 750-911
I Io113ERLEY DRISCOLL
MAYOR Tito%ms ST.Pwouis
DIRECTOR OF PLBLIC PROPERTY/BUD-MG COMMISSIONER
Construction Debris Disposai 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 c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal 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)
— - - (address of facility)
signature of permit applicant
date
dchm:UT J.rc
r
CITY O8 &UE14 ,yVJl6kSSACHUSE Ste!
BUILDLNG DEPART.%WNT
p 120 XV.aSHLotGTola STREET, San FLOOR
TEL. (9711)745-9595
FAX(978)740-9>
1cI_-,f8EM,EY DESCOLL
T'
,���� tfoafAs Sx.
DIRECTOR OF PUBLIC PROPERTY/BUILDL;G CO`13 IISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Atinticant information Please Print Legibill
Nameerc l0usim�s(Xganization[tnfividuall= n• G- �l L,6LZ-
Address: �-j s ��1 erA )4y t.,-
City/State/Zip: '_c:Rd L-" H& Phone#: 9 78 S_-A9 146 t
Are jvon an employer"Check the appropriate boa: Type of project(required):
1. tUr l am a employer with r�L 4. 0 I am a general contractor and 1 6_ ❑Now,construction
employees(full and/or part-time).' have hired the subcomractcim
2.0 1 am a sole proprietor or partner- listed on the attached sheet.: 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9_ ❑Building addition
I No workers'comp. insurance 5. ❑ We are a corporation and its
required_] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [Ko workers' cutup. c. 152,91(4),and we have no 12.❑ Roof repairs
insurance required_]t employees.[No workers` t3.❑Other
comp. insurance required.]
'Any applicant that ducks bort 01 most also fill trot the section below showing their workers'compensation policy information.
}I Inmcawmcm who submit this affidavit indicating they are doing ail walk and ohm hire outside contractors meat submit a new allidavil indicating such
=c'.�mtxtort elms chcsk this box must anaehed an additional sheet showing the none of the sub fitrdetors and their workers'comp.policy information,
I ani an employer that is previdiag workers'compeissadon insurance for my employees Below is file policy and fob site
injarrnaaiotc
Insurance Company Name:
Policy if dr Sclf-ins. Liia" yN: _k/L,,— rte+ ei 4 ,�'� S Expiration Date: fJ t7
Job Site Address: y v-y//na[ A V � City/State/Zip:
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 a 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify funder oke pains and said/es ofpeditry that the informarion provided above is f and correct
Phone is
Official use anly. Do nor write its rkia area,to he completed by city or town nfeiuL f
City or To1vn: __. _ Permit/1.1cenve
Issuing Authority(circle one):
L hoard of health 2.Building Department 3.City/fawn Clerk 2. Electrical Inspector S. Plumbing Inspector
6.Other _
Contact Person: - .. . ---. ._. Phone#: