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8 BECKET - BUILDING INSPECTION a < v Ion ) the C'ommonwe:dlh of Massachusetts y; '!j Board of Biilding Regulations ;mJ Standards CI'I'1'OF 'r Massachusetts State Building Code, 730 C'NIR SALEM �n 'L•,•' Rrrie'Jd I l�n•_'ll l l 'V Building Permit Application -ro Construct, Repair, Renovate Or Demolish a One-or Ttvo-Fa hill Duelling This Section For Offi•'al Usc Only Building Permit Number. D e;lpplicd: _ Budding Oliieial(Print N;une) Signature Date SECTION 1:SITE INFORMATION L I Property Address: 1.2 Assessors Map& Parcel Numbers �? p�k e->t I.la Is this an acce ted street?yes no Nfap Number Purcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed(Jse Lot Area($q 11) Frontage(II) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Munici al❑ On site dis Check if es0 P posul system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ow eTt o Record- /94 Mum(Print) T sT- Uq•,State.ZIP No.and Slrcet rclephone Email Address SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building' Owner-Occupied Repairs(s) X Alteration(s) ❑ Addition ❑ Demolition ❑ I Accessory Bldg. O Number ofUnits_,,j�_ I Other ❑ .Specify: Brief Description of Proposed/1C'' rk': t i Z SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: I Labor mid..\laIerials) Official Use Only I. Building S 131 O I. Building Permit Fee: S Indicate how fee is determined: 2. lAwrical S ❑Standard CityrTosvn Application Fee ❑Total Project Cost'(Item 6)x multiplier — _.x 1, Plumbing S 2. Other Fees: S 1. Mechanical I II\AC) S List: Mechanical (Fire -- ----_ ---------- ------- - Cu,ucssiunl S rotal .\11 Fees: S_ Check No. ('heck Amount: Cash \nunuu: e. Total Project Cost: S �I © ' 0 Paid in Full ❑Outstanding Ilal:mce Due: C5 Kid 35N SECTION 5: ('ONS'I'RUCTION SERVICE'S 5.1 Construction Supervisor License(C'SL) Linn c Number I ir;uiou ale Nunes ul till IJer ' / 1 isl('.SI. I)Pe Isee helots) I. pe Description -- No. :u1J Slrecl / /' �.{/- Cy a U I Inresuicted(Buildings a to}5,UU11 Co. II.1 (() C.Q�L--�- � D J .J„� R Rcslriele I�r?Pamil Dttcllin k )1lllren,.State./IP \I Masao RC' RootingOi%crin ..--._ W'S A induw and Sidinit SF Solid Fuel Ilurning Appliances Insulation '1 bona ;1:mailaddress D Demolition 5.2 Registered Home Improvement Contractor(HIC) 12-4G73 //JAop ' I F-V-q 1 o- _ IRC Registration Number %xiiinf(mn Dwc I IIC oar run u 1•or I IBC Its,y•��stmnl Nano �s� �/ ,(� y �11T A �'/O yr GY n. rlTla / ,(BYO P/'l/P)1 4 Z" Go vri Street / —� Finuil address, No m1J Street �/ Z..-� a .F29291.ZS� t /Town•State,ZIP rele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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...........O SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING / PERMIT I,as Owner of the subject property,hereby authorize Ao l/ " Fra f i p ©" Q l to act on my behalf,in all matters relative to work authorizeh by this building permit application. Print Owner's None(Electronic Signature) Date i SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION By entering my narne 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. Print 0mier's nr:\ulhoriicJ.\gent's Name( '.Ieclrunic Signature) Datc NOTES: I. An Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor (nut registered in the Hume Improvement Contractor(HIC) Program),will no have access to the arbitration program or guaranty fund under\I.G.L.c. 1 2A.Other important information on the HIC Program can be found at \t\t1t IIIA"' % 0v.1 Information on the Construction Supervisor License can be found at U)ttt.11l.li:Fyn II„ 2. When substantial\wrk is planned,proide the information below: Total floor area Isy. ft.) _ 1 including garage. finished bascnlentattics,decks or porch) Gross li\ing area(ss,. 11.) Habitable room count Number of fireplaces.--__ Number of hedrounu Number of bathmunls Number of half haths I\pe of heating i)Steal Number of decks, porches i I tpc al coollllu skitcla 1:11closcd 011e11 1. "lldal Project Square Poo Glue"inaN be iuhsftutcd fit "fowl Projed('list" CITY OF S,VZNf, Akss,kcFiusETT'S SLMDLYG DEP.1RTTtL%T 120 WASHLNGTON STXW. !'O FtOCR TEL (978) 743-959S K11IMER.EY DRLSCOLL FAX(978) 740-984 MAYOR DiO.+w ST.PmBm DIRECTOR OF PLOLIC PROPERTY/St:MnLVG Co -%0U5SIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) , In accordance with the sixth edition of the State Building Code, 780 CUR section 111.5 Debris, and the provisions of MOL c 40, S 54; Building Permit p is issued with the condition that the debris resulting from 111 work shell be disposed of in a properly licensed waste disposal facility as defined by MOL c I 1 I, S I SOA. The debris will be transported by; (name ot'haular) The debris will be disposed of in : (name or racll' (iddmis or rjcihjy) 119 04rulcoo2ermilipplican, ',nn tid 4y CITY OF SiU E.Nta NL1SSACHCSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET, 3ta FLOOR TEL (978) 745-9595 FkX(978) 7.10-9846 KimBERLEY DRISCOLL NLAYOR T'HOStAS ST.PIERRI3 DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLAISSIONER Workers' Compensation Insurance AftTdavit: Builders/Contractors/Electricians/Plumbers Apolleant Information / Please Print Lepih►v Nafnc ti)usiiwi. OrLwniratiorolmlividu;d): TPsr/� Q �A miC/4"AC Address: —?elS d City/State/Zip: -7,E24 J -2! e Are you an employer?Check the appropriate box: 'type of project(required): 'I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction �cmplayces(full and/or part-rime).' have hired the sut�centracWrs 2 I am a sole proprietor or partner. listed on the attached sheet,t 7• ❑ Remodeling ship and have no employees These subcontractors have V. ❑ Demolition working for me in any capacity. workers'comp.insurance. 9, ❑puilding addition [No workers comp. insurance 5• ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. (No workers'sump. c. 152,§1(4),and we have no 12.[] Roof repairs insurance required.) t employees.[No workers' 13.❑Other comp. insurance required.] -Nry applicant drn chvelta box el m,,also fill out the wlliuo W-Owshowina thsir waken'compenntion pulicy information. 'I hvnuuwnen who mbmil this arrldavis indicating they a"doing all worst and than hire outside conlmcton mar sohmit a new amdavil indieasing ouch.Cnmmotun that cheek this box must attached in WdiliurW shot shuwing the name of the sub�cumracto"and Chair works"'warp.policy informmion. fain an employer that/s praviding workers'c ampeusatlon insurance for my emp/ayees Below ix du policy and job site iujannatinn. Insurance Company Name: Policy 4 or Self-ins. Lin d: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). Fjiluru to secure coverage as required under Section 25A ofJfGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 am1/ur one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S2MM a day against doe violator. De advised that a copy of this statement may be forwarded to the OOicc of Investigations of f is DIA for insurance coverage verification. I do hereby certify t e in mud aenohles of perjury that the hiformadmi provided above iv true and correct Phone d• �'�' Offiriul use only. Da not write in this areµ to be rumplered by city ur town,/7L.i L City ar'fusvn: — . . __ PcrmiUf.lccnse p � Issuing Aulhorily(circle one): 1. Board of Ilealih 2. Duildinq Depart "tat .1.Ciiyaown Clerk J. Electrical Impectur 5. Plumbing Inspector 6.Other Contact I'crsun: _ Phone ih. r, Information and Instructions .\lassachusetts 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 ajoint 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 rot 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 sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry 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. Scif-insured companies should enter their self-insurance license number on the appropriate line. City or Town Omclals 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 till 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) and under"Job Site Address"the applicant should write"all locations in (city or town)."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 now 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Oftice of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-?6-05 www.mass.gov/die