B-19-606 - 0118 BRIDGE STREET - Building Permit The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
MUNICIPALITY
Massachusetts State Building Code, 780 CMR
USE
Fc, Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two Family Dwelling
This,Section For Official Use Only
Q Building Permit Number: Date Applied:
JAI
Building official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes no Map Number Parcel Number
ra
1.3 Zoning Information: 1.4 Property Dimensions:
CT
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it) -- ;
Front Yard Side Yards Rear YardAll
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: ' ;
Public Private❑ Zone: _ Outside Flood Zone? Municipalt(On site disposal system ❑
Check if yeg-
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
V
No.and Street Telephone -- Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Des ription of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical Is '900 ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. i Check Amount: Cash Amount:
6.Tonal Project Cost: $1�p DL 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) O d
License Number Expiration Date
Name of CSL Holder E F
List CSL Type(see below) ;
T�No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft..
L
n A Hai ® ul R Restricted 1&2 Famil. Dwelling
City/Town,State,ZIP - M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) pp
77.,< G 1 )pp lR7 ci)ck 1,i— r,—, HIC�Registration umber Expiration Date
HIMompany Name or HIC Registrant Name
No.and Street Email address
Ci /Town,State ZIP 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 of the building permit.
Signed Affidavit Attached? Yes ......... No...........0
SECTION 7a:OWNER A HORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT.OR CONTRACTOR APPLIES FOR BUILDING PERMIT
v
I,as Owner of the subject property,hereby authoriz
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Sigfiature) 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.
e �
PrintOwner's or Authorized Agent's Name(Electronic Signature) ate
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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.Qov/dns
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"maybe substituted for"Total Project Cost"
The Commonwealth ofMassaehasetts
J Department oflndas&W Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mas&gov/dda
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianMumbers
MPH ant Information Please Print Leeibly
Name(Business/Organization/Individual):
Address:_130 T11�Y1, C)t1 S'F'
City/State/Zip: LY=12 A 0 k 9!a-V, Phone M 7 �
Are you an employer?Check the appropriate box: Type of project(required):
1.II am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction
emplioyees(full and/or -time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 9 7. Remodeling
ship and have no employees These subcontractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp•insurance•t ❑Building g addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 I.❑plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.0 Other
comp-insurance required.]
*Any applicant that checks box#1 most also fill out the section below showing the*workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
iContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers,en i ber.
comp.policy nwo
Ion an employer that isprovWxg workers'compensation insurance for my employees Below is thepolicy trnd job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: JJ VJ W C� `�ii(0 Expiration Date.-
Job Site Address- City/State/Zip: S
ak(z-m l O
Attach a copy of the wo;terl 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
fore 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.(i10 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 p enah&S ofperjury that the information provided above Rs a and correct
Signature: - :
Phone#: �r
[6.
(ficial use only. Do not write in this area,to be completed by city or town ojWat
ty or Town: PermWUcense#
uing Authority(circle one):
Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
Otherntact Person: Phone M
: Oly OF SALEIVI M4SSAMMEn
BDFrn'
120 WA9AWMSZWTq YOPLOOR
UL."745-"9595
RIIdBER�YDRiStIDLL FAX(1978)740.9846
MAYQR T)JOtAS ST.PI"
DREGTCa CFMWC MM rr/BIZLDM OUMMCM
Construction Debris Disposal Affidavit
(requiredfor all demolition & renovation .work)
In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris,
and the provisions of MGL coo,S54;Building permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111,S150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
He(n —
(name of facility)
(address of facility)
S' Katur applicant
D liq
(today's date)
f
The Commonwealth of Massachuseds
Department oflndusbial Accidents
Office oflnvestigadons
600 Washington Street
x Boston,MA 02111
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elects icians/Plumbers
AAPPHcaat Information Please Print Leeibly
Name(Business/organization&aiviaual):
Address:—[So v m sd n S-f-
City/Statelzip: Lyn/l 4- OLqO Phone#: -?" (
Are you tin employer?Check the appropriate box: Typa of project(required):
4. I am a general contractor and I P J ( eQ
II am.a employer with g 6. ❑New construction
Employees(full and/or -time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.mP•insurance.t Building addition
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their
11.❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs
insunince required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.❑Other
comp.insurance required.]
•Any applicant that checks box#1 must also fill out the section below showing their workers,compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If th a sub-contractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providing workers'coinpensahon insuranee for my employees: Below is the poll y and job site
information
Insurance Company Name:
Policy#or Self-ins.Lic.#: W C ,�A 4A Expiration Date:
Job Site Address: - City/State/Zip: Sat(z..w _o l�7 O
Attach a copy of the worker['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 cer ftft under the p d enalkes"ofperjury that the information provided a is a and correct
Signature: - Date: t:c
Phone#:
OPkial use only. Do not write in this area,to be completed by city or town oJ)'rciaL
City or Town: Permit/Ucense#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: