10 LANGSDON ST - BUILDING INSPECTION C q0 cK 2_-7-7b
t
� The Commonwealth of Massachusetts JJ81
-� �
Board of Building Regulations and Standards
Massachusetts State BuildingCode 780 CMR
ed Mar 101
Building Permit Application To Construct Repair,Renovate Or Demo _ A 11: Z I
One-or Two-Family Dwelling
QThis lection For U :t3se .
_O Bu,i Prrml:I Fttmliea . . Date ,pharl:
building Ot$icie!(P�tffame9 `." She.
- �E,CTION It BITE} RMi1TI13N
1.1 Property Address: n S. I 1.2 Assessors Map&Parcel Numbers
Lla Is this an accepted street?yes_ no Map Naber Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(it)
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: 1.8 Sewage Disposal System:
Zane: _ Outside Flood e? Municipal 13 On site disposal system 13Public Private 11 Check if ye
SECTION 2; PROPRRTV OWNERSHIP
1 ,
2.1 Owner'of RetR�ordpl} 2
Lo 1
Name(Print) City,State,ZIP
Email Address
and Street Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKS toheck allthat apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ Alterati0n(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of=d Worle:
A -Lin r<
o C-c . .
`SECTION 4:ESTIIYlA D CONSTRUCTION COSTb
Estimated Costs: Official Use Only
Item or and Materials
1.Building $ �l7j UV v 1. Buikti IS *Iiia:$ Iiadkate hove fee is determined:
0 Standard Ckytrown Application'Fee
2.Electrical $ /0 O C�O O Total project Costs(Item 6)x multiplier x-
3.
3.Plumbing $ /J V rr O 2: Other Fees:
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $ Total All Fees:$
S cession
greck No. Check Amount: Cash Amount:
6.Total Project Cost: $ p v p ❑Paid in Fall [3 Outstanding Balance J1ate:
Mtht_�p q �12.
SECTION S. CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
K, �j-0�,�- -0-,c 1, License Number Exphation Date
Name of CSL Holder C S '- J
I p p List CSL Type(see below)
Z (� C._,S I A (-A3 V
No-.and Street ll� 2 rel TWO Drs tion
rv , G v�-�-S �,/� U ( U Unrestricted...... " to 35 000 cu.ft
/
R I Restricted l&2 FamilyDwelling
City/Town,State,ZIP M Masonry
RC I RoutingCoverin
ws Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 RegisteredRomeImprovement Contractor(HIC) 7.
C./f
ec. S S HIC/Registration Number Expiration Date
HIC Company Name or C Re ' Name 0
�W 4?
N .and Street� Email address 2a3; �1 } 6 L&-3 3rd
Ci /Town State ZIP Tel one
SECTION 4:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MGI-c.152.4 25CM
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 ..........❑ - No...........O
7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN "
WNEtt'S AGENT OR CONTRACTOR R , MG . -_.
1,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) Date
SECTION 7b:OWNERr AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is tr d accurate to th of owledge and understanding.
Print Owner's or Authorized Agent's Name(Ele c SignatureDate
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 muLmass.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"maybe substituted for"Total Project Cost"
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Construction Debris Disposa/Affidavit
(required forall demolition and,.renovition work)
In accordance with the shah edition of the State Building Code, 780 CMR, Seclon 111.5 Dem
and the provisions of MGL a1Q S 54; Building Permit a is issued with the
condition that the debris resuking from this work shall be disposed of in a property licensed
waste deposit facility as deftned by MGL c 111,S 154.
The debris will be transported by.-
(name
y:(name of hauler)
The debris will be disposed of in:
(name of facility)/
� L�7 ti
(address of facility)
ature of applicant
Date
r.
The Common weaM ofMasspchuseds
DeporAment oflddastrialiActadents
I CongressSWr4 Suite 100
Boston,AL4 01114-2017
www massgovIdia
Workers'Compensation Insurance Affidavit:Builders/Contiradors/Eleebidans/Plumbera.
TO BE FILED WITH THE PERBOWMG AUTHORIff.
stipiano
Name(Bu,siesselp,niration%Indivi"P.- L< J .-Q-LA. p
Address: we-v (x
City/State/Zip: �c �. `S . Phone
#:
Are you an empbyerr tSeek the appropriate bus: of TO 6d .
1.01sm p employer empbyses(tail�d/mvM- )' 7. 0 New ., ..
construeson
21 am e.sok peopaigir,orpmmership apdheve no.eraype vvor}mg forme m 8: Q Remodeling
say capactY pb vi, 'comp fielwance required)
3 01 am a homeowrdsaaiog air wodc aaYeeN:1No wmkes'enmp in+maacs ..)1
9. O Damolitibn
10 0 B,a7aug eddfion.
4.01 am a homeowatrand will be hiring coutmctors to conga all wank w mypmputy. I wHl
eraua that all conbaetmeidwhave wmkers'rompemmation iasnaoee ormsok 11.0 Electrical repairs of additions
poprietme wtthmeoaptnyees• 12: Plum repabWadditiods .
5.01em ageverw cautoadoiand lhave tumd the sub�tie efine lidded oa Poe amehM Aeei: 13.uRoofr
Ihme.sub�Mwt mbave®PloymmdbawwodmWc mp ioaaaocet �
6.0 We sox coapontianaudm officeishave exertimdtheirriBEt ofes®pbun perMQ.a - 14.01�fhFr . . -. . .
752,§I(4),end vee tiaeem employees.lNo waclda'camp�ar«pmedj - - .
•Any applifffiat eheeio<iiasaYl mus ado 6D omtbe section)agues mawing thea watfuds aaoppohryfot�anm.
t Ifomeowms who srknit 9jbaffidaviticditaQdg ere aswork®dtheytine oubide wasmmtsumacsu:w afadavn indimeng assn:
tconazimra that checkthii ties Hunt etmcbedmaddiro�el sheet alio"wkgf&mide of Ode'sub-coffiedma audamte uti�"v oimt�oae eomliG+ffive
employee..Ifthe sub—hutpshave.emADY-4 ibey,muopwielvdnea-wodma':Clamp-polmy 1100ar, :.. ..
I am aq employer that isprovidiag workers'Compeadagon hwdaraneefor m3 empJgyees Boiaw is thep0Uc7aadl4 ate
injorrrtedoa.
insurance Company Name: WP S
Policy#or Self-ins.Lie.#: N pp (0 1Y d' Expiration Date: 7 - '7'
Job Site Address: /U �� (� v C1 City/3tate/Ztp: C' Fl L w � U L,S,Zo
Attach a copy of the workers'compensation polity declaration page(showing the pokey number and espinglandate).
Failure to secure coyonge as required under MGT.'c. 152,§25A is a criminal violation piz idhible by a fine up to$1,500.00
and/or one-year impriscontent,as well as civil penalties in the fixm of a STOP WORK ORDER and a fine of up to$25.0.00 a
day against ibe yfol+itac.A copy of this statement maybe fwwarded to tine Office ofJoves iptions ofthe DTA far inniraMce
coverage verification.
1 do hereby eerfi ander tbepains and pamaMm ofpajay that the mformaao r provided above a tree and ee rrea
O,l/Jcial ase onf . De nd write m this area,to be eosepided hY carry or toren offsow
City or Town: Pereak(License#
Issuing Authority(circle one):
1.Board of Bealth I Building Department 3.Cityfrown Clerk_ 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Coated 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 ofhire,
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 aparhnents 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 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 ofpubtc work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting s»tbonty."
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)name(s),address(es)and phone number(s)along with thea o ntificate(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 Departrnent 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-insuredcompanies 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 Depsrtutent 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 icense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only mbrmt 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 proof that 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 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.#617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/die