16 SAVOY RD - BUILDING INSPECTION $/OS 02-e,-3
rl
The Commonwealth of Massachusetts
CITYRF0
t Board of Building Regulations and Standards
:4 Massachusetts State Building Code,780 CMR
Revised Alar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
On—or Two-Family Dwelling
This Section For OffiqW Use Only
TBuilding Permit Number. Da Applied:
U44,47
at(Prim Name) Signature Date
SECTION It SITE INFORMATION
1,1Property Address: 12 AtWairs Map&Pa
nd N b
,
1.1 a Is this an accepted street'?yes_ a, Map Number Parcel Number
1.3 Ing Otto": 44� IA Property Dimensions-.
. I ?,!�?
Zoning District Pr4as6,i use Lot Ao:ajmrffT4tC4W
FroNage�00
1.5 Building Setbacks(ft)
Front Yard Side Yards Rcm-Yard
-
Required Pruvided Required Provided Rolumsd + Provided
1.6 Water pply:(m.G.L c.4o, ;,t) 1.7 Hood Zone InformatiuM. 1.8 Sewage Disposal System:
Zone: c Flood�pmV
Public FPO — ona"d Municipal W<sitc disposal system ❑
Private 0 Check ify"In
SECTION 2: PROPERTY OWNYMS11111"
21 OVgcpfRc rd: VarZ- .3r�
Name(Print) City.Surft.Zip
L(0 SA (O rz�oAAO F Ace,com
No.and Street Te eplume Frnail Address
. I SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
:N::cw�Cmstmcuua(3 Existing Building owner-Occupied Repairs(s) El I Alteration(s) k�Addtuoux 0
Demolition 0 1 Accessory Bldg-E3 I Number of Units Other 0 Spocify-
Rnief-I)PScription off"nDposed S Wozlke: FJP-114,0rt
WA44ork Id couva
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offidal Use Only
(Labor and Materials)
1.Building $ 0 A50, 1. Building Permit Fee: Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ 13 Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ j000 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire S
Suppression) Total All Fees:Si_
Check No Check Ammane Cash Ammunt:—
�A
1"Y
SECTION 5: CONSTRUCTION SERVICES
51 Construction Supervisor License(CSL)
cs o96S2rn _ 5/►S 118
&�4 r _ License Number Expiration Date
Name of CSL Holder
Sy /J %gu- List CSL Type(see below)
No.and Saw 3t G- T e Description
Unrestricted(Buildings cu.ft.pQ" I—RA Restricted l&2 Fmi Dwelling
Citylfovm,State.ZIP - - M Masonry
RC Raofirig Covrmg
WS Window and Siding
�� SF SolidtiRuining Appliances
I Inwiadmon
Telephone r Pel address D Demolition
5.2_ Registffrd homev/em�cnt Contract"(HIC) �z�� t(f IOII
�gr��+ Htc Registration Number ExlTmhonDate
/
ljo-and SueetEmail address
M&ABL,WMQ, NA0%g4'6 X8 34
Cityffowa,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M-G-L..c.152.§ 25C(6))
Workers Cmnpeusatmxt Insurance affidavit must be completed and submitted with that application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit: !
Signed Affidavit Attached? Yes........_ Ivo...........❑
SECTION 7a:OWNER AUTHORIZATION TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR"PLIES FOR BUILDING PERMIT
I,M Owherhf the subjec p ,hereby authorize aT{J�+
to ac ' majfm relative to work authorized by this building permit application.
Print 0cr'a Name(EI Sign 1 Nate
SECTION 7b:OWNER' AUTHORIZED AG ECLARATION
Sy entering my name below,i hereby attest under the pains and Penalties of perjury that all of the information
contained in this plication is true and accurate on the best of my knowledge and understanding.
��MIL 9llo! !L
Print Ounces of Authorized Agent's Name(Electronic Signature) Date �
NOTES:
I. An Owner who obtains a building permit to do hiAcr own work,or an owner who hires an unregistered contactor
(not registered in the Home Improvement Contractor(HIC)Pmgmm),will not have access to the arbilra l-on
program or guaranty fimd under M.G.L.c_142A.Other important information on the HIC Program can be found a
-: Information on the Construction Supervisor License can be found at �'.•::;
2. When substantial work is planned,provide the information below:
Total floor area(sq.R). (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 haiflbalhs
Type of heating system Number of decks/pouches
Type of coaling system EneJosed Open
i s. "1'cutl:'mixt ldttare CG..'.ant�`may 21e�lttstitlitCi vttr"!M21 i'rttir:et?:65[' j
i CITY OF S.�tii, N'LXSS.A.CHUSETTS
13tiHMMIG DFPART1t&\T
• 130 WAsi mNGTS
ON STREr,r FLOOR
TEx- (976)745-9595
1'.Aa(976) 740-9646
KI\IBERL F-Y DRISCOLL
MAYOR TrlOaus ST.PtFRRa
DIRECTOR OF PUBLIC PROPERTY/BL:MDL\GCONIUM SIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A s licant Information Legibly
Please Print e ibL
Name(Basinss ftanizationtlndividual): r aT— at CLp
Address: 2uer..g�� c *?--
City/State/zip: 4*40P2 F4tta4nr
Are y an employer'Check the appropriate box: Type of project(required):
1. 1 am a employer with 2 _ 4. ❑ I am a general contractor and l 6. ❑New truction
employees(full and/or part-time)." have hired the sub-contractors
2_❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. emodaling
ship and have no employees These subcontractors have & ❑Demolition
working for me in any capacity, workers'comp. insurance. 9. 0 Building addition
[No workers'comp. insurance 5. [1We are a corporation and its
required.] officers have exercised thew
10.0 Electrical repairs or additions
3. 1 acct a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. hero workers' 13.0 Other
comp_insurance required,j
•Ane applicard the efiWks box el nowt a6u 6a out the serum below showing their workM'wnrye+wion puticy iof na ti,a
*I t nrauwnts who submit this affidavit indicating they aro doing all work and then hire outside cmtruzonx Onto sabmit a new affidavit indicating such.
=c'.mnnsaon that chrek this box mmo anaehed an addiaotd sheet showing ft tame of the sub ntrapen and thea worker'romp.policy inGurmutim.
!am on employer that is providing warkers'compensadon insumnte for my employees. Below is the poncy and jab site
nrnation. /1 t� Ww
Insurance Company Name: Ck" �� I
Policy h or Self-ins.Lie.#: W G { &114 n; Expiration Date; -/I�'
Job Site Address:-1 & S"O(� EP4D Ciry/Stme/Zip: `�1N1 y
,Attach a copy of the workers'comp usation 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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
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 dee DIA for insurance coverage verification.
!do hereby terrify under die pains and penallies of perjary that she informaNan provided above is true and correcL
5i ennwrci Date•
Phone#
OKIcial use only. Donor write in this area to be completed by city or town ofc'iat
City or.Town: Permit/I.1cense
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityffowo Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Perwn• _ __ Phone#•