17 CAMBRIDGE ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
�. Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code 730 CINIR SdMar 1 ) � Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Divelling
Chis Section For Official Use Only
Building Permit Numbery' Ap
BuildingOfficial'(PnntN:ime) I
SECTION [:SITE INFORN TIONl
..
l.t Property, dress: 12Assessor Is arcel Numbers
_
1,1 a is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water upply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Iysposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal Von site disposal system Cl
Check ifyes❑
SECTION!:, PAOPERTY'OWNERSHIPL
1.1 PAW t of eco d: y�i 7 0
Name Print) City,State,
i5 97� Ml_
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED.WORKV(check all that apply)
New Construction ❑ Existing Building Cl Owner-Occupied Cl I Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ NumberofUnits Other ❑ Specify:
Brief Description of Proposed Work": 3�
SECTION 4: ESTINLATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1. Building Building Permit Fee:8 rntiicatehow fee is determined:
t. faectrical S YOb ❑Standard.CityrrownApplication Fee.'
❑'rotal Project Cost(Item 6)x multiplier x
3. Plumbing S O( ? L Other Fees: S
1. M-chanical (IIV.\q 3 List:
. %Ixhanical (Fire $
Su res ion) _ Total All Fees:.S_
Check No. Check Amount: __C;1Sl1 Aniom t:_—
r, I'utal Project Cost: 5 (3 Paid in Fill ❑Outstandin; U;il;incc Uiro:
J ---
• ♦ 1r
SECTION 5: CO;NS'TRUCTION SERVICES
5.1 Construction Supervisur Liecuse(CSL)
License Number — Gs irati i Dute
Nnmc of CSL I!older
List I;SL Type(ace below) (/
r a Description
No. and S ect
q U Unrestricted(Buildings up l0 35,000 cu. tt.
Restricted 1&2 Family Dwellin
Citytruwn,State, ZIP ivt Masonry
RC Roofinit Covering
WS Window and Siding,SF Solid Fuel Burning Appliances
I Insulation
Tcle hone Email nJJress D Demolition
5. istered Hame Im roven nt Con cto (H[C) Z� <E
k1IC Registration Number pirati n Date
f IIC man N ne ur iIC Re trant/Ty
No.and t� ivy P Email address
i /Town•SState ZIP role hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 02. 1 25C(6))
Workers Compensation Insurance affidavit must be c9mpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc f the building permit.
Signed Affidavit Attached? Yes .......... No...........0
SECTION 7a: OWNER AUTHORIZATION TO BE C01VIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dntc
SECTION 7h: 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 a licati n is tru a d accurate to the best of my knowledge and understanding.
Print Owners ur Autlturited:\ nt's N,une lectrmtic Sisunuue) Data
NOTES:
1. 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 Hoine Improvement Contractor(HIC) Program),will not have access to the arbitratiun
program or guaranty fund tender M.G.L. c. 142A. Other important information on the k1IC Program can be found at
www.m;us.auv/oca Information on the Construction Supervisor License can be found at www.nrts . �u��rdi,
2. When substantial work is planned,provide the information below:
Total flour area(sq. It.) --___ _(including garage, finished basementlattics,decks or porch)
tiros; living:era(sq. it Ribitable room count
Nouiberoffireplacc ---__----- Number of bedrooms
Nunlbcrufb,uhrnums Number ofhAt'baihs ___------ —
I 'IW of heating .iy iicin — -- --- Number of decki/ porches —__—
I'Npeofca,din" syitenl ..-- _-.- __.--..- .--"-"— F:ncloicd__--- (.)pen
I. f„t.il P[ rt iyuara Pi way he sn i,tirw:d t;,r 'I'm tl hoicri (.b.t'•
--w.- aye .xn.a++w'm �.��..- ��+n-,wws *E..wan....,�,�: �
n
o
CITY OF lx 1%LksS ALCHUSETTS
BuiLD4\G DEP PMMS NT
p 120 WASHLNGTON STREET,310 FLOOR
uttsrt�r TEIL (978) 745 9595
FXx(978);740.9846
(CiNiBERLF-Y DRISCOLL T HONIAS ST.PIERRZ
MAYOR'' DIRECTOR OF PUBLIC PROPER7`Y/BUI DLNGCONWISSIO.iER'
Workers' Compensation insurance Affidavit:Builders/Contractors/Electric[imuelumbers
4 licant intnrmadon PI ase Print Legibly
AA
Naine(BusinesslOrganizatioNlndividual): pp l� q _i =-
AJtlress: �
City/State/Zip ;YD,,,; ._. a0'M Phone#: 971-F01--00/r [ `'
Are y age player?Check the appropriate box: Type of pr t(required):
1. I am a employer with y 4. El am a general contractor and 1 6. ❑ construction
employees(full and/or part-time).* have hired the sub-contractors
2.El am a solcproprietar or partner-
listed on the attached sheet t 7. Remodeling
ship and have no employees These sub-contractors have 13. ❑Demolition
working;for me in any capacity. workers'come insurance. 9. ❑ Building addition
(No workers'comp.insurance' S. ❑ We area corporation and its '-
required.). officers have exercised their !0.❑Electrical repairs or additions 5
3.❑ I am a homeownerdoing all work right of exemption perMGL I I.❑Plumbing repairs or additions !
myself.[No workers'comp, C. 152,g I(4);and'we have no 12.0 Roof repairs
insurance required.)t employees. [No workers' 13.❑Other
comp.insurance required.) -
•Anyappllcumthatcheck hb oim.lot.fill out thosetalon below showing their workers'mmpeniation policyinrormation -.
t I htmeuwrs rs.who submit this ieidavit indicating they am doing all work and thca him outside contract=main submit a new,aMdavit indicating such.
:Comractora that check this box must attached an ad iaonal sheer showing the name of the subi'ontraclom and Ihetr'workers'wrap.policy in(omution.
l um an employer that is providing workers'compensadon insurance for my employeex Belowts the policy and job sire
injormalion
Insurance Company Name:
��r e ! p� t� i
Policy N or Self--ins.Lie.N:l�+�l A w / ` 7 Expiration Date: 6 �/
Job Site Address: / 7 � f 4 " City/State/Zip:
Attach a copy of the workers'compensatlo6 p Iicy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MG c. 152can lead to the imposition of criminal penalties of a
fine up to S1,500,00 and/or one-year imprisonment,as we11 as civil penalties in the form of STOP WORK ORDER and a fiat
of up to S250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigutions,of(lie DIA for insurance coverageycritication.
/do hereby certify ties th pains - null ojprrfuty that flilormu/a pravidrAabove is true and correct
OJTcia/use wdy. bo not write in this area,to be completed by city or town af Wal
City or•town: Permii/Llcenxe#
Lutsing Authority(circle one):
1.Board of Health 2,Building Department 3.Cilyrfown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: -_..____ Phone N:
CITY OF S,6v.ENf2 itiW&kCHusETTS
r
Bt:MDLYG DEP.tRTONT
120 CVM.HC4GTOV ' iO
v s=r T'_L. (978) 743-9595
fu.NCOERE EY ORtSCOLL FAA(978) 7-W-9343
t�,L�YOR T$l0►tt3$T plgArtg
DuECTOrt OF naLIC pROPEQTy/SLMnLYG COSL\(tSSIO.VER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work).
fn accordance with the sixth edition of ilia 3tata Building Coda, 730 C�1,fR section 111.5
Debris, and the provisions of MCL a 40, 9 54;
Building permit k is issued with the condition that the debris resulting from
this work shall ba disposed of in a properly licensed waste disposal facility as defined by NIGL c
I 11, S I50A.
The debris will be transported by:
o
(numo ut'hauter)
The debris will be disposed of in :
(name or t elia X-
"T ire oep,,nii appli•ant