37 CHESTNUT ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
Board of Building Regulations and Standards
�tassacllusetts State Building Co C[[Y OF
U� I ide, 730 CNIR SALEVI
�71 Revised Mnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
[his Sectioh.For Official Use Only
Building Permit Number. D3(e AppIitsd.' ".
Official(PntNamz) : Signature J, Data
SECTION 1:SITE INFORNIATI N.
1.1 Property ddress: - 1.2 Assessors M p& P 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 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: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2:, PAOPERTY OWNERSHIPL
wn rt of Record-
N 0.b�^
Name(Print) VCity,State,ZIP
No,and Street" Telephone ` Email Address
SECTION 3: DESCRIPTO OF PROPOSED WORIO'(check all that apply)
New Construction ❑ Existing Building Orl Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition Cl
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only,
Labor and Materials
I. Building s lSOoc� 1. Building Permit Fee:5- Indicate how fee is determined:
2. Electrical $ S�oQ ❑Stand d ar ..City/[oven Application Fee.
❑'[otal Project Cost (Item 6)x multiplier x
3. Plumbing 3 d Ooo 2. Other Fees: $
1. Mechanical (1IVAC) 3 List:
5. Mechanical (Fire $
Su > tression) _ Total All Fees:.$
-- - --Pro Clieck No. Check Amount: Cash Amount
ject Cost: S[utal C�l.JO
� 0Paid in Full Cl Outstandim, Ilnl;uice I)oe:
SECTION 5: CO:Ns"TRUCTION SERVICES
5.1 Cottstruction Sup�erv�i�sor Liccuse(CSL)
License Number E.epir;uiun Dam .
Name of9 ./lXjbvr0.•(2r `D
List CSL Type(see below)
� /p►,��_ Type Description
No. attJ S :
Q U Unrestricted Buildin s u to 3i,000 cu. R.
7V R Restricted 13r2 Family Dwelling.
City/"ro�vn, State, ZIP - DI blasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
57� zrs0yaw P - --�-f'Te�'` J�G I insulation
l'ela hunt Email address D Demolition
^.2�Registered H me ImprovementCon ctor(H[I Ad C /7/y,S 31 Zvir
l/1 HIC Registration Number Expinition Date
(II IC 'UrTINGY Nal e^r IIIC;Regist a Name �� � AdC ` ray
'a.an� t et � C�
�. Email address
City/Town,Slate, ZIP l Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be mpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuano 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereb attest under the pains and penalties of perjury that all of the information
contained in this application is a and, c r to to t e best of my knowledge and understanding.
I'rintar's ur AuthurimL went s, .unv(E tct unit gnanuc) Date
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 florae Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under D.G.L. c. 1.12A. Other important information on the H!C program can be found at
www.mass.�'ov oca Information on the Construction Supervisor license can be found at tvww.m:us.wy.4 in
2. When substantial work is planned,provide the information below:
-total tloor:trea(ski. (t.) _(including garage, finished basement/attics, decks or pot
tiros; living area(ski ti.l f Ltbitable room count
Numberof tit glaccs__--_ ---- Numberofbedrooms --_.--
Nundnr of bathrnoitts Numl?cr of halt:baths _-_—_-- --
I'vpc of he:uing sysicin . _ ..__ ----_._-- Number oFdeck 'porches
f•,peoFeoolin� ;y;tam _ f�nclosed Upcn
{. I,?i it I'i-�j"a �quai� f��ot i • m.ty hQ ;ub;titur I rnr 'r"t d I injcd
I
I
Cfn of S y, .1C.Elf, itiL1SS.ACHUSETT'S
BI:=LYG DEPARTLENT
120 M%suLYGTON STREET, 3"FLOO(t
T'-L (978) 743-9593
E.4L.EY DfLISCOLL F.1.Y(978) 7-10-9344
� UYOIt -1110 i3ST.PIERM
DIMCTOrt OF PLOLIC PROPERTY/8L'IL.DLNG CONNISSIONER
Construction Debris Disposal At't7davit
(required for all demolition :utd renovation work)
In accordance with the sixth edition of the State Building Coda, 730 CMR section t l 1.5
Debris, and the provisions of IMGL e 40, S 54;
Building Permit k is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal Facility as defined by NIGL c
It 1, S 150A.
The debris will be transported by:
- A zI�Z
(name uChaulcr) 0
The debris will be disposed of in :
nnma of Y lily)
Oddress of t'jolily)
s iyn�ntt uC permitapplicant
d.uc .
.� CITY OF S.'� xm, '1%Ws kCHUSETI'S
BUILDING DEPARTMENT
• , 120 WASHINGTON STRHET,.3"P FLOOR
.. TEL (978)745 9595.
F.{it(978)730-9846
KIMBERt RY DRISCOLL THO3,US ST.PIERRB
LiAYOR DIRECTOR OF PCHLIC PROPERTY/lIUMDING CON UiSSIONFIt
Workers' Compensation insurance Affidavit-Builders/Contractors/Eiectricians/Piumbera
A r licanf information PI age PrintLe ibl
Vatne(OusinossOlwriizatioNlndividuap:
Address
City/State/Zip �%6 2 Phone l#: i7d �U%—UO/�
A�re u an employer?Check the appropriate box: Type of project(required):
4. ❑ I am a general contractor and 1 6. w construction
1.LVJ l am a employer with have hired the sub-contractors " ❑ '
employees(full and/or.part-time). 7. Remodeling
2.❑ 1 am a sole proprietor or partner listed on rho attacked sheet.
,hip and Have no employees These sub-connectors have S. ❑ Demolition
working,for me,in any capacity.. workers'comp. insurance. 9, ❑Building addition
[No workers'comp..insurance S. ❑ We area corporation and iu
officers have exercised their 10.❑Electrical repairs or additions
.. required.); . _.
3.❑ i am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or additions
myself.[No workers'comp. c. 152,ql(4),and we have no 12.❑Roof repairs
insurancerequirefl! employees:[No workers'. 13.❑,Other '
comp.insurance required.]
Any applicant that chu:ks 6ax Of meatataY fill out the section belowshowing their workus'compensad, pulb; inforrnation.
t 11,mcuwmtrs who submit this affidavit indicating they ate doing all work and than hint outside contractors must submit anew affidavit indicatim;such.
--C mrxton that chuck this box most anochad an additional short showing the name of the sut•eont,"and thetlunulta ',comp,policy information. I
1 am an t nployer that fs providing workers'compensation insurance far my employees: Below is the polley and Job site
injortuorion - ` n —A. _
lnsurancc Company Name: C�l/ au-�-�—
Policy 4 or Self-ins.Lie.M. Al1d(R� ,�����c9 Expiration Dater
Job Site Address: � rµA '.�! City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy num her 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 imprisonmen4 as well an civil penalties in the Corm of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a t:opy of this statement may he forwarded to the Office of
Investigutiuns ul'the DIA for insurance coverage verification.
l do hereby rerrijy r er th)pain a pen /ales ofperjury that the mforntallon provided above is true and correct
Date.
Ph 4;
Official use only. Da oar write in this area;to be cuatpleled by,city orlowa offieigI
City or'rown: PermG/Wcense#
issuing Authority(circle one):
1. Board of health 2. Building Department 3.City/fawn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other._ -
Contact Person: _.____ Phone 0: