45 WINTHROP ST - BUILDING INSPECTION i z(o 3 z_
The Commonwealth of Massachusetts ` . CITY OF
Board of Building Regulations and Standard SEP 22 q: @+EM
Massachusetts State Building Code,780 CM 1F Revised Mar 2011
W Building Permit Application To Construct,Repair,Renovate Or Demolish a
rtrt� One-or Two-Family Dwelling
This Section For Official Use Only
QBuilding Permit Number: Date plied:
� p
n Building Official(Print Name) Signal= _ D�/
SECTION 1:SITE INFORMATION
1.1'P�rokerty Address
Srtr�Gu� 1.2 Assessors Map&Parcel Numbers
r(1 `7� '1
1`J 1.1a Is this an accepted street?yes - no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District 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: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private 13Zone*
if yes[] Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O er'of Re rd: p
� ,5 _6�PiN') V)R Gly
Nar�n ( rirint) ,. City,State,ZIP
�VV ri� & 6� s,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief D scription of Propo d Work2: T '
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ ('�'.L'� 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ash ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ u
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
-Suppression) Total All Fees:$
h Check No. Check.Amount:--- Cash Amount
6.Total Project Cost: $ ry ❑Paid in Full ❑Outstanding Balance Due:
't l ZCI KA VL 1, o c, .0 .
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 7 ) LS_05Y?�/� f , ( - Zd f
r'h� C�dU`/7i1 1 l License Number 1-�5 Expuatir Date
Name of CSL Holder
List CSL Type(see below)
2g�
No.and Street Type Description
77 U Unrestricted uildin s u to 35,000 cu.ft.
6, Qa1A V 6 l
R .Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RCRoofing Covering
t3 i.7 j C WS Window and Siding
Sq SolidFuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) + L5534 rj•
F//^J/ C6aJ c.c li-��`�7� �l�C� HIC Registration Number Expiration Date
fflc Com an me o C Re tr Name91Z,�
14,E �VICLO
N15nd Street d(�j �� Email addressMR
( per
Ci /Town,State,Z G Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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 o the building permit.
Signed Affidavit Attached? Yes .........: No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,
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) Date
SECTION 7b:OWNER`OR 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 true and accurate to the best of my knowledge and understanding.
Pnnt er)or AuthbTdea Agent's We(Electronic a e Date
NOTES:
L 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
w1v .mass.eov/oca information on the Construction Supervisor License can be found at www.mass.eov/dps
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 Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
'( www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information qq Please Print Legibly
Business/OrganizatiBusiness/OrganizationName:
Address: F, 4 1 zrj 17
City/State/Zip: �V�s� Y M09OC1 j5— Phone#:_ c( 7 � 19�/5 `l2�-
Are y an employer?Check the appropriate box: Business Type(required):
1. I am a employer with employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/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] g. E]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.❑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.❑ Other
*Any applicant that checks box#1 must also 611 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#1.
I am an employer that isproviding w, orker�'compggsation insuranc form employees. Below is thepolicy information.
Insurance Company Name:_ ��zlr_)'bC171 }/ �-�,e
Insurer's Address: 1�f6,�p�rdp q.�/ `
City/State/Zip: �ed�7y l � V l' G� !�` 7 V
Policy#or Self-ins.Lic.# + 2.�0o H 17 L,1-'J Expiration Date:
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, under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: / Date: C �(%� ' +O
Phone#: 6 �?
Official use only. Do not 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.CitylTown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia