12 CHESTNUT ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Y OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Revised Mar 2011
Q Building Permit Application To Construct,Repair,Renovate Or Dei 8 ,P 2: 51
-T" One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:,
Building Official(Print Name) Signature _ Date
t SECTION 1: SITE INFORMATION a a'
1.1 roperty Address 1.2 Assessors Map&Parcel Numbers
' t S f
i.la Is this an accepted
sd street?yeses no Map Number Parcel Number
1.3 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al On site disposal system ❑
Publio J Private❑ Check if yeA P P y
er'of Recor —
SECTION 2:'PROPERTY OWNERSMPt
2
1 t 1 W 1U--t
Name(Print) City,State,ZIP
No.and Street Telephone Email Address tILUvD.C C&L
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Sp ify:
Brief Descn non of Pro osed Work': L �e
i" t, E7
�t^AA Ala 1 G a1 on /Si oar 9 ! n
SECTION 4:ESTIMATED CONSTRUCTION COSTS ��o
Item Estimated Costs: :Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ VO ❑Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ Ott 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees•:$
Su ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 7 ❑paid in Full ❑Outstanding Balance Due:
�v—� 1'bV,tctc. u� — Ni,S pt- S
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructio upervisor License(CSL) Lt 4f �d_
zm.�n / Ve License Rumber Expiration Date
Name of CSL Holder
� C List CSL Type(see below)
No.and Street T Description '
" _L�/�/1J-�- � t QO� U Unrestricted uildin u to 35,000 cu.ft.
City/Town,State,ZIP ' M Restricted 1&2 Family Dwelling
- RC Roofinj Coverin .
WS Window and Siding
SF Solid Fuel Burning Appliances,
4617/oV C 6 I Ltsulation -
Telephone . - Email address D Demolition
5.2 Regilltered.Home Improvement Contractor(HIC) 1,2
4 j j S-1'-7
6C -yt�/ - HIC Registration oNumber Expiration Date
HIC Company N e or HIC Registrant Name _
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 Issuance of the building permit.
Signed Affidavit Attached? Yes........ No............❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize _. �er� )/�O+r __, � 1
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) bate
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
�i/n�this
J7application
is Jtrue and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent'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.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.R (including garage,finished basementlattics,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 beating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage'may be substituted for"Total Project Cost"
CITY OF S�U.&%v1, ,INv'fAss kcHL'SETTS
• BUHMING DEPARTMENT
120 WASHINGTON STREET,3'n FLOOR
TEL (978) 745-9595
FAX(978)740-9846
KI\tBERLEY DRISCOLL
MAYOR THOMAS ST.PMRM
DmECCOR OF PtiBLIC PROPERTY/BL'II.DING CO\LMMIONER
Workers' Compensation insurance Affidavit:Builders/Contractors/ElectriciansIPlumbers
Applicant Information Please Print Legibly
i�
Name(Busiri ssDrpnimtion/Imliviclaw):�L�-T4i��✓l�D
Address: -5 2aCY Lla,,JD -9-i
City/State/Zip:J IA!: ?�''-/"-h- dfla 7 Phone#.ZI)7-796-6 !G U
Are you an employer?Cheek the appropriate box: Type ofproject
1.C,i am a employer with—a 4. ❑ 1 am a general contractor and 1 et(required):
e have hired the sub-connactors 6. ❑New construction
employees(full and/or part-titre). 7. �oemodelin
2.❑ 1 am a sole propriemr or partner- listed on the attached sheet.S +` g
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insumace. 9. 0 Building addition
(No workers'comp.insurance S. ❑ We are a corpomtion and its )0. Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I L[]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'
comp. insurance required.] 13.0 Other
'Any applic nt that chocksent b #1 mu l also fi11 out the swim thebw ebwieg their workers•compensation policy inromenioa
'Iforecoam rs who submit this attldavih it H,,fimg they are doing aU work acid thus hire outside conttaUous mint submit a note affidavit indicating such.
=('emtaemra that chock this box mhmt,ached an additiotml sheet showing am muse of the atbmnflaztps east their whukow emnp.Policy insmantion.
l am an employer rhat is providing workers'compensadon lnsamocefor my employees. Below Is the policy and job site
information. I
Insurance Company Name: // Z 4-kA S L/JG
Policy#or Self-ins.Lie.#: CJ�T U t� , .2 �f J �r�_ Expiration Date•[[11.�i:�
Job Sire Address: Cl�b_Srd✓lT[�! City/SmtdzipSt�t - 1 AMA- OtY70
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. Be 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 rert&ander the pains and penaides ofpedury that the infori adore provided above is true and comet
Sil_naNurr �'� Date!
Okrsd use only. Do not write in this area to he completed by city or town official
City or Town: Permit/f.lcense#
Issuing Authority(circle one):
1.Board of Ilealth 2.Building Department 3.C)ty)Towu Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
i CITY OF S[11.L NI, 2NvLxssACHUSETTS
BvmDmG DEP IRT%l&NT
` 120 WASHINGTON STREET,3'o FLOOR
2IML 07%74rr9595
FAX(978) 740-9W
KINIBERLEY DRISCOLL
MAYOR THONM ST.PMUR
DIRECTOR OF MBLIC PROPERTY/BUTI.DING COMUSSIONER
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
111, S 150A.
The debris will be transported by:
r
(name of hauler)
The debris will be disposed of in :
Same of facility)
(address of facility)
signature of permit applicant
date
JcbriviiJoc
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
+ Construction Sunerrisor
I
License: CS4)668"
ETHAN E now ` NX
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Office of Consumer Affairs&Business Regulsfion
+ ; OME IMPROVEMENT CONTRACTOR
egistration A92456 Type: '
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ETHAN DOW ` R 6-Y
95 ROCKLAND ST �, err
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SWAMPSCOT7, MA 0190�?
- Undersecretary
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