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B-19-1220 - 0002A BUFFUM STREET - Building Permit l.i The Commonwealth of Massachusetts Board of Building Regulations and Standan OCT I I A 4 ITY OF Massachusetts State Building Code,780 CIA � �ALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only; Buildmg Pertrut Numberf5, Date Applied (� .Buildmg Offici (Pant Name) ;Signature Date SECTION 1:SI INFORMATION 1.1 Property Address.a e 1.2 Assessors &Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information• p �J O 1oer_ .4 Property Dimensions: =`r" pp� Zon' tstrict Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) --AJ Front Yard Sidi Yards Rear Yard Req fired Provided Required Provided Required Provided 1.6 Wa r Supply:(M.G.L c.40,§54) 1.7 Flood Zone Informati 1.8 Sewag isposal System: Zone: _ Outside Flo one? Public Pd. rivate❑ Check if ye Municipa On site disposal system ❑ SECTION 2 PROPERTY OWNERSHIP', Name(P t) City,State,State,ZIP No.and Street Telephone Email Address SECTION 3 DESCRIP ION QF PROPOSED:WORKZ(c ec all that apply New Construction❑ Existing Buildin Owner-Occupied Repairs(s) Alterations) Addition q' Demolition ❑ Accessory Bldg.❑ Number of UnifX I Other ❑ Specify: Brie scription ofZ&dWorkZ: � xzwl M� 1 r SECTION ', STIMATED C NSTRUCTION COSTS Estimated Costs Item Official Use pnly Labor and Materials 1.Building �� 1 Bumg Pernut Fee $ Indicate how'fee is determined '❑Standard Ctty/TownApphcahon Fee:; 2.Electrical $ a s ❑Total ProjectCost (Item 6)x multiplier x 3.Plumbing $ `_ 2 Other Fees >$ 4.Mechanical (14VAC) 5.Mechanical (Fire $ Suppression) otal Ail Fees Check No Check Amount Casl Amount 6.Total Project Cost: $� ❑paid to Fu11 ©Outstanding Balance Due t� y ^ r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) J- License Number Expiration vate Name of CSL Holder I� '�n List CSL Type(see below) � ►V\a�� / Type 'Descn hon N6.and S� p•. i J" nA O U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date Inc Co m any Name or HIC Registrant Name j No.and Str t c ��J Email address City/Town,State,ZIP Telephone SECTION 6 WORKERS'COMPENS TIUN INSURANCE AFFIDAVIT(M G:L c.152 § 25C(�) Workers Compensation Insurance affidavit mu4 be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issulmee of the building permit. Signed Affidavit Attached? Yes.......... No...........❑ SECTION 7a.OWNER AUTHORIZATION TO BE COMPUETED'WHEN O.WNER'S AGENT,OR CONTRAC,TU�•APPL•IES FOR BUILDING PERMIT � ,•,.. ;-, , I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work a ed by this building permit application. Print Owner's Name(Electronic Signature) Date � ' SECTION 7b`OWNERI ;AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contain s appli 'on is and accurate to a best of my knowledge and understanding. P Q er's or nth rized en s Name(Electronic Signature) Date , 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.mAaLgov/oca Information on the Construction Supervisor License can be found at www.mass. ovg /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" P a .a �+Cry OF S��Ni, XSSACHUSETTS BI:ILDL1G DEPARTtE.�iT t 1201WASHINGTON STREET,r FLOOR TEL (978)745-9595 FA.r(978)740-9846 KI.\IBERIEY DRISCOLL THOMAS ST.PIERPM MAYOR DIRECTOR OF PUBLIC PROPERTY/BL'II.DLtiG CO\L\IISSiO;`iER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeEibIx Name(Busimss:Organizationrindivideaal): v��--- Address: r- City/State/Zip: 6�9 J Phone#: ! I t 1 Are you an employer?Check the appr p a , x: Type of project(.required): 1.❑ am a employer with am a general contractor and 1 6. ❑ w construction mployees(full and/or part-time).* ve hired the stab-contractors 2. am a sole proprietor or partner- listed on the attached sheet. 7 emodeling hip and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity, workers'comp.insurance. 9. ❑Yuilding addition [Ito workers comp.insurance S. ❑ We are a corporation and its 10. ' ectrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11. umbing repairs or additions myself.(No workers'comp. c. 152,41(4),and we have no 12. f repairs insurance required.)t employers.LN'o workers' 13.0 Other comp.insurance required.] 'Any applicant that checks boz#t must also fill out the section below Atowing their workers'compensation policy information. t I limwowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :C.mtras.-tors that chuck this bore must attached an alditional sheet showing_the name of the sub-eontractws and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job slta information: \ Insurance Company Name: Policy#or Self-ins.Lic. Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy aeclaration 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Re advised that a copy of this statement may be forwarded to the Offce of Investigations of the DIA for insurance coverage verification. I do hereby certify nr r the pai and enalt/es of perjury that the information provided above is true and correct 5i wat tre: P o official use only. Do not write in this area,to be completed by city or town official: City or Tuwn: _,... Permit/License# ____�_..__�_ ___.•._.._ . Issuing Authority(circle one): 1.Board of llealth 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact`Person: __.__ Phone#: dotloopsigna[u evenficaUon dtfp,bglYTxF70bz:P�6x TRAIVELER5.1 _ WORKERS COMPENSATION� QNE .TOWER•SQUARE HARTFQRD CT; 06183" ° ABILITY AN EMPLOYERS LI POLICY TYPE V. INFORMATION PAGE WC " 191' 19 POLICY NUMBER � ,1N170 42 G; :NEW 1`9 INSURER THE CHARTER OAK FIRE INSURANCE COMPANY �NCCI CO CODE 15318 1 -:INSURED PRODUCER TOWNE IKANGEMENT I+LC AUTOMATIC DATA PROC, INS 3 MAPT,V TERRACE 1 ADP BLVD # 625 NEWBURY, MA"'01951 ': ROSELAND, NJ U7068 _ t Insured !S A LIMITED LIABILITY COMPANY Other workplaces and identification numbers are shown m the schedule(s) attached 2 , The;pohey"penod is from,:01 10. 19 to of 10 20 12 01,A M atthe insured s mailing address; 3: A WORKERS COMPENSATION INSURANCE Part_One o#the policy applies to the Workers CompensatfonLaw'ofthe states) fisted here ;EMPLOYERS.LIABILITY INSURANCE Patt Two of thes,polfcy applies to work in each state fisted fn _ item ILA The;limris'of our hability under Part Two are o Botlfly Injury by,Accfdent $ 100,ooa Each Accident Bodily Injury by Disease S 500,o0o licy Lim it po : Q Bodily Injury by Disease $ 100,000 Each Employee C OTHER STATES INSURANCE PattThree of the policy applies to'the states if any listed here' AL AR A2 CA' CO CT DC DE FLE GA HI ::IA ID' IL Ild KS KSr LA MD ME MI MN' t �� MO MS M1` NC. NE NH NJ NM N17 aNY OK_OR PA RI SG SD TN TX 'UT VA _ D Thfs policy includes these endorsements and schedules f o -SEE L`ISTING_OF,,ENDORSEMENTS EXTENSION OF INFO PAGE 4; The premium for tt K poUcy wdl:be determinetl,by our Manuals"of Rules Classifrcations Rates and Rating Plans All requiredmformatwn'issubJecfto vencatfon"and change byauditto be made ANNUALLY r � DATE OF ISSUE o1 .il` 19 AD ' AOFFICE PAYROLL � 70A +� � 'PRODUCERx 'AUTOMATIC DATA PROC INS ,XV770 �� ' F �005235 a• - _ - 6:56 PM EDT - yL ddodoop vented l y i ,. CITY OF SM.&N111 TU xSSACHUSETTS BL:UMNG DEPsan.MN i 130 W ASNINGTON STREET,310 FY.00R TEL (978) 745-9595 FAX(978) 740-9846 KIMB RL Y DRISCOLL MAYOR THoNtAs ST.PmnE DIRECTOR OF PIBi c PROPERTY/BU DING CONMSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c i 11, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : G,f✓ (name of facility) (address 'facility) d�V/ �j s't, afore of pe it applicant date dcbrisafT doc Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Ma6gachusetts 02118 Home Improveme�tractor Registration Type: Individual " Registration 181273 ERICA.TOWNE ' ' Exp iration:i ration. 03/17/2021 ONE MAPLE TERRACE NEW BURY,MA 01951 r n .s Update Address dress and Return Card. „. , t W 20M-05/17 Coinmonweattfi of Massachusetts Divi3ion of Profess�ofial Licensure uil Board of<Bding Regulations and'Sta aids co; skr nrisot CS-104096 w _ fires 08/ 019 . F ERIC A TOWS •� �` ONE MAPLE'. NEMURY MAI 3 . f)fS�f 11t1 ' Commissioner