107-107R BOSTON ST - BPA-16-62 EXTERIOR REPAIRS The Commonwealth of Massachusetts CITY OF
t Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR Revised Mar
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
p This Section For Official Use Only -
Building Permit Number: Date Applied' O
a'
o :n
rn
Building Official(Print Name) '.Signature 1 , Dat s y� '
SECTION I: SITE INFORMATION ?
P13
P�_perjy�1�r�ss: 0� GG� 1.2 Assessors Map &Parcel Numbers NO
l U71S !J )f- M
Is this an accepted street?yes V no Map Number Parcel Number C
CJ mng Information: 1.4 Property Dimensions:
1 Zoning District Proposed Ue Lot Area(sq ft) Frontage(ft)
9 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.40,3 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION2. PROPERTYOWNERSIIIP'
2.1 nerrofcord:
CA- e c'qA'kI 70
Name City,State,ZIP
t)/ � g _4 o mi uker r tAo-yAV
No.and Street Telephone Email Address
SECTION 3: ',DESCRIPTION.OF PROPOSED WORTe(check all that Apply),
New Construction❑ Existing Building It Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessor Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed W rk2: o r e t
d
S16CTION 4: ESTIMATED CONSTRUCTION COSTS
Item E ILimated Costs: Official Use Only
(Labor and Materials
1. Building $ 1. Building Permit Fee $ Indicate how fee is determined:
2.Electrical $ ❑Standard Cityfrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees' $
4. Mechanical (HVAC) $ List.
5. Mechanical (Fire $Suppression Total All Fees: $
3
Check No. Check Amount. Cash Amount:
6. Total Project Cost: $ ED L2 O ❑Paid in Full - ❑Outstanding Balance Duc:
f
i
P
SECTION 5: CONSTRUCTION SERVICES
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5.1 Ci nstruction Supervisor LiI-gense(CSL)
�o n �l�FE2 L/fi V Licen 09mber 6
License Number Ex iration Date
Name of CSL Holder
/� List CSL Type(see below) L/
�O 4 C-��1�(/`G ��%��-�' / _ Type .. Description
No.and Street
U Unrestricted(Buildings u 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
Citylrown,State,ZIP ! M Masonry
RC Roofing Covering
WS Window and Siding
g t / �j SF Solid Fuel Burning Appliances
a7p Vo C�`IyG�LCNIQ�' 1/"�l /�/7(/(/ �' I Insulation
Telephone f Email address D Demolition
5.2 Registered Homed IImproven'tent Contractor(HIC)
To / 3 O y
41 n hiL l/'Pr'� MC Registration6 4uum—ber Expiration Date
Hj,C Company Name or HIC Registrant Nam5—
No.and Street Email address
Sra � ,�- A 1-9� d 15:20 92 it '000YL
Citv/Town, State,ZIP ? Telephone
SECTION 4J;VORKERSi COMPENSATION INSURANCE AFF DAVIT(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 Issu a of the building permit.
Signed Affidavit Attached? 4es .......... Y No ...........❑
SECTION Tar OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUHAING PERMIT
M
erty,hereby authorize J rx 1(ZVe-
ers'relative to work authorized by this building permit application.
!f'im FEM) Date /V
SECTION 7b: OWNEW 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 tnpie and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent'=_Name(Electronic Signature) Date
4 . 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 Horne 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.eov/oca Information on the Construction Supervisor License can be found at Lv3nX.mass.gov/dgs
2. When substantial work is plTined,provide the information below:
Total floor area(sq.ft.) (including garage,fmished basement/attics,decks or porch)
Gross living area(sq.ft.) k Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms r Number of half/baths
Type of heating system $ Number of decks/porches
Type of cooling system E Enclosed Open
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
S
I
1
i CITY OF Sm.E;tii, �'I�ASS<ACHLSETTS
I BuII.DING DEPaRTJiENT
: (t• 120 WASHLNGTON STREET, 3"FLOOR
TEL (978)74S-9595
Fix(978)740-9W
I\fBFR( FEY DRMOLL THONWST.PtEM
VSAYOR
DIRECTOR OF PUBLIC PR0PERTY/BL'II.D1!`1G CO\L<QSSIO;`iF1C
Workers' Compensati +n Insurance Affidavit: Builders/Contractors/Electricians/Ptumbers
Applicant Information ! Please Print LeeiblY
Name lBusiness.Organiz tiorvlmii%idual):
Address: ?o /
City/State/Zip: Phone l#: c3i79 LIP-6A!�CIY
Are you nn employer?Check tha appropriate box: _ TyVNc
project(required):
}•❑ I am a • oyer with ! 4. ❑ 1 am a general contractor and 1 6. w construction
et oyees(full and/or part-time).' have hired the sub-coturactors
2. am a sole proprietor or partner- listed on the attached sheet i �• ❑Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working for tnc in any capatkity. workers'comp. insurance. 9. ❑Building addition
[No workers*comp. insurance 5. We are a corporation and its
to.El Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL l 1.0 Plumbing repairs or additions
myself.[No workers'comp.° c- 152,§1(4),and we have no 12,0 Roof repairs
insurance required.)t employees.[No workers' 13.❑Other
comp. insurance required-]
'Any applicant than checks box#I must also fill out the section below Aowing their workers'wmprnatim policy information.
t I Inmeownr,who submit this affidavit indicating they ate doing all work and thm hire outside contractors must=limit a rxw affidavit indicating such
:Comncton that check this box must anich4d an additimuil airtl showing the rune of the subconttactons and their workers'carp.policy information.
l am an employer that fs providin1 workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name: i
Policy#or Self-ins.Lic.#: ! Expiration Date:
Job Site Address: k4 City/State/Zip:
Attach a copy of the workers'co�rpensation 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 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 S -0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigati -of the DIA for insurajpcc coverage verification.
t
l do hereby r. i nde he ains jai d penalties of rjury that the information provided above'LY true and correct
Si.1nat ire: �t E Date! E
Phone#:
Ojrcial use only. Do not write In this areq to he completed by city or town offrciaL
City or Town: PermidUcense#
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#:
E