6 BROWN ST - BPA-13-441 _ :a I'hc Cunununsvrahh of htassachuscns
s Bu,nrJ of'Iluilding Regulations and Standards CITY OF
ht;tssadnuetrs I Slate Building CuJu,'79U('hIR L\LIiAI
� Building Permit Application TO Construct. Repair. Ill`IIUVatC Or 1)ellU)IiYll a
$)ne• or rn -li"amsll- Divelliu,p
This Section For 0160ul Usc On1
Building Permit Number' Date,`Ip icd: AA
UuilJing Oillciul(Print N�une) Siytsalurc G�
D Its
SECTION I: SITE INFOR 11AT10N
161 Pr ty 1JJrns+:� 1.2 Assessurs Nlap dt Parcel Numbers
- S� M-��
I.la Is this an acre led street? es no Mop Number Parcel Nun:tser
I.J Zoning Informations 1.4 Property Dimensions$
Caning Distriel I'mpusuJ t/se Lon Area Is Iq
y 1.3 Bulldlnt Setbecks jig) Fmntag pl)1
Front Yard Side Yards
Required Provided Ruor Yuri
Required IkuviJrd Nryuired Provided
1.6 Water Supply:(M.G.I.c. 40, §54) 1-7 Flood Zone Informations
Ihibllc❑ Pris ate❑
Zone: _ Outside Flood"Lune? I.tl Sewell Disposal System:
Check If)cs❑ Municipal❑ On$ite Jbpuyul s)stem ❑
2.1 Owners of Records SECTION Is PROPERTY OWNERSHIP,
%Hv1-rr Pl�l�:
Nmsu(Print) Y;,/n-
6 6 s 1 City.5tata,l.IP
Nu.:mil Street -
' re�lvphon@ Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ E.ristiny Building❑ Owner•Occupied ❑ Repalrs(s) Alterallon(s) ❑ I Addition ❑Demulilion ❑ .Accessory Bldg.❑ Number of Units
Brief Description of Proposed Works: Other ❑ Spcuily;
SECTIO,V a: ESTI,AIATED CONSTRUCTION COSTS
Item Evinsated Costs:
It ibur curd Materials) Official Use Only
I UuilJing S 'F 37Sh 1. UuilJing Permit Fee: S Indicate husv the is determined:
'. Flecirlcal S 0 Standard City:Tussn Application Fee
I I'hunhing S as l7� ❑Total Project Cast,I Item 6)x multiplier
'. Other Fees: S -- -
I J. \Icch.lnirul ill\ \f'I S List:
--
i �u .vcssionl S fatal \II Fees: 5
r, Ibtal Project Cust: S w O- � ('I,c.A Vu. _.. (heck .\nwunt
/ /�/ ❑ ^.:iJ in Full 13 Ihitsiandioy II.ILmcc D w:
unitructioll Superlisor License((SL)
-_P 63 Daly
IC01.19 NuolbO
K(31(►U
pe lkscrivfion
r,
_Z7 I inrestriocd 01011di'llis 111"to 35.1100 W It
,4,,. ind stn:vt
—Jvlricted I&I I
cil)!l mi.slate. KC K,%)I*"' Co%crin
--VA—.S Window uld',lull'
Sp solid Fuel Morning Appliances
losulution
I mail adJN-,.4
11,Conlirlicior(1111C)
Q'I _1��CyC)e,.
.4.3 Registered Ilume Improvement
I lic lusillrallun Ntantcr Espinuiun Dula
PVC C>(V SC
lh
�
51—ccompin) NaInVor I lit' kiii-lifunt Naing
6� rft
/0 3r�
No. uld Stroll' !�oet -7
Tel one
Ci Town. State,ZIP SECTION 61 WORKERS'COMPENSATIONINSURANCE AFFIDAVIT(M.G.L c. 157.1 2SC(6))
Workers Compensation Insurance affidavit must be completed and submi I tted with this application Failure 10 provide
this affidavit will result in the denial of the issuance of the building Permit-
Signed Affidavit Attached? yes ..........D
No...........Cl
SECTION AUTHORIZATION TO HE�CONIP!!IETED'%V P E;4
L——————WCT�7&t OWNER AUTHORIZA
OWNER RACTOR Ai' FOR BUILDING PERMIT
' AGENTORCONT'
1, as owner of the SAW Property.hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Uwler'll NWIIC tLla.......C'Stlinu'Urt)
SECTION 7b.ONVNEWOR AUTI
_IIORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the inrormatiun
I- a�racl:u to to(lie best of my knowledge and understanding.
contained ill t is app I
DUIQ
NorES1
n o%vner Mia hircian oil ull
.\n register
\ \%hu obtains building per it to do his,htr awn work or
a %vill Ila have access to the arbitration
llr tour
(,lot registered in the Hulile It grant can be touild 34
tl,!mpr;�cil lit ContracturIHICI Program).
142.%. othcr illiporlaij information on the HIC Pro
program or guarant) l'uil der.M.G.L. C. . i Supemisorl-k-;Insecanbe round
n the Constructict
i information a
lien iubstailtial Fork is planned, protiJe the inlonnmiun below:
• I including garage. finished bascillellL.111i", necks or rorcill
Total 11kiorarva i 4q. 111 11 abillabld Count count
Crosi 11%ilig lle'l 1'4- 11 nhcr t4b,cdrovills
ofilrclllac"
Nlip,herol hadiroolils NuoilherolAc,ki, por0hci(11wil
I)pall11c.1filIg i)00),
1,rolc,t s,porc I 0,11.1tic, 014%
CITY OF SM.EM, AXSSACHLSETTS
BUIMING DEP\R-IMEIiT
N. 120 WASHLNGTON STREET, 3a'FLOOR
TM (978) 745-9595
` F.ax(978) 740-9846
KI\[BFRT t±Y DRISCOLL
i�YAYOR T1iOhtAS ST.PIERRB
DIRECTOR OF PCBLIC PROPERTY/BCILDLNG COMMISSIONER
Workers' Compensation Tnsurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Tnfirrmation Please Print Legibly
Name(Busitlo&Organization/Individual): K2Vt W cdc /i1 t'
T
Address: /� Nr0�2t1 l S
City/State/Zip: r f E'4XPr� 4 t 5 Phone ✓ :l4( �+- `'Its 1 J 6 ->
Are you an employer?Check the appropriate box: 'type of project(required):
1.0 1 am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction
r. r�employees(full and/or part-time).• have hired the sub-contractors
2.C7 am a sole proprietor or partner- listed on the attached sheet.I ?• `O emadeling
ship and have no employees These sub-contractors have s. 0 Demolition
working for me ip any capacity, workers'comp. insurance. 9, 0 Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. (No workers'comp. c. 152, ¢t(4),and we have no 12.0 Roof repairs
insurance required.)1 employees.[No workers' 13.❑Other
comp, insurance required.]
-Any applicant dal checks box el must also fill out the section below showing their workers'compenottiun policy infurmation.
r 14",owner,who submit this aBidivit indicating they arc doing all work and then hire outside contmct in,ratan submit a nenv antdavit indicating such.
:Cnmms ion that check this has must attached an additional sheet showing iho n one of the subs antractors and their workers'comp.policy information.
lam an eitiployer that is providing workers'compensation insurance for my employees. Below/s the policy and fob slla
information.
Insurance Company Name:
Policy 4 or Self-ins. Lie. 0: Expiration Date:
Job Site Address: City/State/Zip:
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 S 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 S250.00 a day against the violator. Re 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 p l
`ena'tles of peryury that the information provided above is true and correct.
Sienmlre: /^ Y�`� Dare' UCI ?tf 9-O/,�Z,
Phond 1• �� �C7�/ �5 6�
Ofjiciul use only. Do not write in ilds urea,to be completed by city or town offlclat
City ar Town: Permit/f.lcense 9
t
Issuing Authority(circle one):
I. Board of health 2.Building Department I City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
(
CITY OF S.ULEM, NLUSACHUSETTS
BUM.DLNG DEPARTMENT
130 WASHLNGTON STREET, 3° FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINiBERLEY DRISCOLL
\MAYOR THo.%w ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUMDDJG CO%L\QSSIONER
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
I11, S 150A.
The debris will be transported by:
Grtc �, �iaoOsc.
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature pt ea oo�n applicant
date