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15 RIVER ST - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards Ct�A` F Massachusetts State Building Code,780 CMR Revised Mar 2011 O� Building Permit Application To Construct,Repair,Renovate ttjs03 �} 4 One-or Two-Family Dwelling Ihis Sequa For t#loial. . Baildng Feaatlt.N�tmber: .' : Applied: 1ArW ,� 3) �(� BailtbugDil6s're�(Yrmt e) Signature V. e 1�C1YON 1:$TFJC II+i1�0�14ATI+Div 1.1 pe Address: / 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq it) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards Rgar Yard Required Provided Re4u6ed Provided Required I Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system O Check if es❑ SEC7'ION2. FROPERTY'OWNERSIIIPt 2.1 Owners otRe rd: /A,r Q��,3� Name(Print) City,State, ZIP /� /voy �ltr P v r� ` 72 No.and Street Telephone Email Address SECTION&DESCRIPTION OF PROPOSED WORK$(eheclt all that apply) New Construction j Existing Build40 =0wner_�Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑Demolition ❑ Accessory Bldber of Units_ Other ❑ Specify. Brief Description of Proposed WorkZ: e– SECTION 4:ESTIMAT];D CONSTRUCTION COSTS item Estimated Costs: Official Use Only (Labor and Materials ].Building $ 30 _ [2. Indicate how fee is determined:Standard Cdy/fown Application Fee 2.Electrical $ Total Project Cost?(Item 6)x muliiplier T3.Plumbing $ Other Fees: $ 4.Mechanical (HVAC) $ st: ' 5.Mechanical (Fire $ Total AH Fees:$ Su ression Cheek M. Check Amount: Cash Amount: 6.Total Project Cost: $ p Paidin pull p outstanding Balance Due. C� �i�l e�S 6� 6-62-0/ -62.0/ 0to >7XY- rnfatu3tD 111 c . lof3 , i SECTWN 5: CONSTRUCTION SERVIc S 5.1 Construction Supervisor License(CSL) C S 09A 3 94 0 17 A n eSL I r7. r,, License Number Expiration to / Nie of Ider - J � List CSL Type(see below) 3 Say �n o L H No and Street o/ Q S Aly lam'n'l Gt OI✓ �d TJ 3 R Umestnc[ed to 35 000 cu.ft. .. Restrictedl&2F®il Ci own,State,ZIP M masomil RC Roo Cg- -i-WS Wmdow and S- ' ,+� SF Solid Fuel Burning Appliances Telephone Email .2. .�—a I Insulation Tel one Email address D Demolition 5.2 Registered Home Improovement Contractor(HIC) l.' 4 C7S 4 �7 ll o e / " /7 Q HIC Registration Number Expirfition Date HIC�Cm Name or HIC Registrant Name2 r2�j �r4nfiQD / y� ��PIQOI• Co No.and Street C� % 1 ©� �9 [i iEmail addresl Ci /rows State ZIP J G Telephone SECTION Q WORKEIM COItIp"ENSATION msuRANCE AFFIDAVIT OLG.L c.152.4 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..........17 No...........O §W--TION 7a OWNER AUTH ORIZA–TIONTO SECOA41t'LETED?1VIIEIN WI R'S AGE,T OR(Q qR. FO _ M PEiRAM 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:OWNER!OR AUTHOItI=AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained' this pl' 'on is true and accurate to the best of my knowledge and understanding. 2 > Owner's Autho o4id Agent's Name(Electronic Signature) D ,. NOTlES: 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.massgov/oca Information on the Construction Supervisor License can be found at MMMmass.eov/das 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basemenUattics,decks or porch) Gross living area(sq.ft.) Habitable room count ' Number of fireplaces Number of bedrooms Number of bathrooms Number of halFbaths 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 Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 'f www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information y Please Print Legibly Business/Organization Name: /f ke ,,tt Address: 3 'r7' Seerrtt ,�12.� e, 4 L—"i City/State/Zip: i Z-e 01,9, Phone#: Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail e rpart-time).* 6. ❑RestaurantBar/Eating Establishment 2. I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11 ❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that is providing workers'cam enation insurancefor my employees. Below is the policy information. Insurance Company Name- Sv e 7' 91 s Insurer's Address: Srrr qot -n/ Orr S 77 ^/rP�'G� !'P?/ /vrd G�✓3J City/ta� : .,V,,X/l1Cr 4 ..1 Y/ �. G DO S4tt0 n Jf. Ju/lp let-) . o;,/ rxpy✓✓ Policy#or Self-ins.Lic. o/ 3 74 Expiration Date: 1012112-0& 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 c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be 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, der he pains d penalties of perjury that the information provided above is true and correct. Si nature: �� Date: Phone#: J Oficial use only. Do trot write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia • i 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 an 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 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 of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented 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 your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'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 line. 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/license 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 submit one affidavit indicating current policy information(if necessary). 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 dog license or permit to burn 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-N ASSAFE Fax# 617-727-7749 www.mass.gov/dia Form Revised 02-23-15 C 17YOFSALEIV4 MASSAMSETr Btnj)mDEraABWrr : 1M WAsW=WSnuarvPROCR BII�EWBYDb'�O�L Fex74498t6 r MA]M 7}nusST.P�E DmRcxm crPUUxPrxFMy/DUMnMCaMWSffCNM Construction Debris Disposes/Affrdvvit (required for•all demolition and,.renovition work) in accordance wo the sbM edition of the State Buy Ong Code, 7W Clog, Section 111.5 Debris; and the prowWons of MGL M,S 54; Building Pem*B is Issued with the condition that the debris resulting from this work shag be disposed of in a properly licensed waste deposit facility as defined by MGL c Illy S 154. The debris will be transported by.- (name y:(name of hauler) The debris will be disposed of in: (name of dllty) (address of facility) S' nature of applicant -2 ate