10 CHURCHILL ST - BUILDING PERMIT APP � • �
I , I ------ _ _
:a I he Comnwnntallh ol'Musn,�chuscl�s
i;. '�� 13uurd uf 13uiWing Rrgulations ;uid StandarJs CI"Il' OF
�' ,:, MfI55pl'IlU5CIf5 S17IC DUIIlI10� CO(�t. �SO CI�IR ti,\LG�I
�a,,.. rr.•��.,�-d.i��„•�nu
13uilJing Pennit Application 'fo Construct, Rrpair, Rcnov;rte Or Demulish a
Onr-ur T�ru-Fumilr Du r!lin,p
This Sectiun For O(ficiul )se On1
Uuilding Permit Numbcr. Date ppiicd:
UuiWing 011icial(Prinl N�une) Signaturc Uut•
SECTION 1:SITE INFORDIATIOIV
- I.i Pro�erty AJdress: Lj Assesson M1lap& Parcel Numben
�D �h�a t-,
I.I a is this an ,uceptad street?yes no M1�up NumFer Purccl Numinr
I.J Zoning Infonnallon: I.i Property Dimenslona:
Zuning Di>lrict PrupuscJ Usc Lol Arcu(sy It) Pronlagc(�l)
1.3 Building Setbecks(R)
Front Y;ud SiJc Yunls
Rcar Y:vd
Reyuircd Provided Reyuircd Provided Neyuind PruvideJ
. 1.6 Weter Supply;�M.G.I.c.J0, §5a) IJ Fload Zone Informxtlon: 1.8 Sewege Dieposal System:
Public ❑ Pri��atc❑ Zone: _ Ou�iJe Fload Zone?
Check if �esO Municipal O On site Jispuwl systcm ❑
SECTtON2: PROPERTYOWNERSHIP�
2.1 Owner�of Record: .�7 ,
C h a_fC L.�.S_- A—ry � P S A Ls r+z MA
N;unu 1 Print) C ily.Stotc.!.I P �
jOCtiv��'k�u- S lol7 -6g0 � (� i10
Na anJ Street �felephont Email AJdmss
SECTION J: DESCRIPTION OF PROPOSED WORK=(check all thrt npply)
Nrw Construction O Existing Buildin Owner-Occupie� Repairs�s) Alteretion(s) ❑ Additiun ❑
Demolition ❑ ,4ccessory Bldg. ❑ Nwnberof Units Other O Specil'y:
DriafDescrip�ionofProposrdWork�: t � ��te w�
���t sF2 �ti�— �='L.a-r ST{�i�""- �£2�� (.1PP 7i.��
■. r
SECTION �: ESTI��IATED CONSTRUCTION COSTS
������ Estimated Costs:
ILabur and .\I�Irrialsl Ofliciul Use Only
I. Ouilding 5 I. BuilJiny Permit Fee: f Indicate how f'ee is derennineJ:
'. Gicctrical g ❑Standard City,?uwn Application Fee �
O Total Pro ect Cust��item 6)r multi her ___ .e
� i. Plumhing S � � P - -
. Other Fees: S /�
I �. .,i«i�,��,��:�i ��i, :,r� s ��5c---- --�p_, !N
� �. \Icrhuniral iFirc
I tiuppro5>iUnl 5 ToGll ;\II FCCS: $ '—_ —�—_'-�_— ���-�'-....._.. .
� n. Tulal Projcct CusC 5 ('hc.A Vu. ---Chcck :lmuunC - ---- C.uh \m�iunl: ..
� ❑ Poid in Full ❑OwstanJing 13ul;mcr Duc:
-,�6,,33b�
�
SECTION 5: CONS-I-Rt1CTION SERVIC'E'S
5,1 Construction Supervisor License (C'St.)
1,
•
----------- --
Liansc Nuniher Pq,iration Date
Name oft'Sl, I folder
�_ 3 � _(-SJ t—✓�1-J�.,�.b_ c'�Fi— Y
No. and Street
4Q C7p�lr e=11i��_
List CSL 1) Pc Isco below)—
.I., PC Description
(I l inrostricted (Buildings ti to 19,000 cu. 111
R Restricted L@2 Faind Docllin
M Mhson
_�y
(ilii Iben, State. LIP
RC' Roolin Covcrin
W'S Window;md Siding
-- ._
SF Solid Fucl Burning Appliances
1 hsulation
I cle hone F.mail address
D Demolition
5.2 Registered H�ome Improvement Contractor (HIC)
f! ., A7 ^.-- C -.-'L Ck r—
IIIC Registration Nunthcr F.apiruioo Uuw
1-11C Compan) Nunn or I IIC Registrant Name
Z 2 w o-- C e'
Nu. Succi
-��r f�l� rrr�a o ,�rr� 9 -7X s -3,(sa3w
Email address
Ci /Town, State, ZIP reictilione
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152.4 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 ........... 17
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 Nmne (Electronic Signature) Date
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 true and accurate to the best of my knowledge and understanding.
Print Owncr's or • uthorire , rout s mne (Flectrunie Signature) Dow
NOTES:
I. 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 Hume Improvement Contractor MIC) Program I, will mr 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
,,,,,, ntr.. ,•„% ,�,,I Information on the Construction Supervisor License can be found at „),y.nms< 1.t-% -It',
2. When substantial work is planned, provide the information below:
Total fluor area (iy. ft.) _ ( including garage, finished basement attics. decks or porde
Cross living area ( sq. It.l -- _ _-- ---- - _ Habitable room court
\umber of fireplaces..__ Number of bedrooms
Numherofbathrooms Numberofhalfhmhs .
F.) pe of heating S) Stem Nunthcrofdecks, porches
I') lie ofcooling.%Stoll _ --.... _..._ Endoscd _ _. -__Open _-
i
1. "fond Project Square Footage- iva) I,e Substituted Ior "Total Project Cost" I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Wit? www. mass.gov/dia
�Vorlcers' Compensation 1 ,surance Affidavit: Builders/Contractors/Electricians/Plumbers
Dplicant Information Please Print I i't�illls
Vlame
-\ddress:
�.in'/Stat
.Are you an employer? Check the ap�r
I am a employer with �_
employees (full and/or pan -time,`
I am a sole proprietor or partner
ship and have no employees
working forme in any capacity.
[No workers' comp, insurance
required.)
I am a homeowner doing all wor
myself, [No workers' comp
Insurance required.) t
priate box:
4. ❑ I am a general contractor and I
have hired the sub -contractors
listed on the attached sheet. t
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp, insurance reouired.l
Type of project (required),
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or adtiiuvc
1 I.❑ Plumbing repaus ,I additi� _
12 F1 Rooficimus
13.❑ Other
applicant that checks box N t must also till o tire secuon below showing their workers' compensation policy information,
homeowners who submit this affidavit indicaun they are doing all work and then hire outside contractors must submit a new affidavit indicating sucu.
_tractors that check this box must attached an rdditional sheet showing the name of the sub -contractors and their workers' comp, policy inform:nju,..
! am an employer that is providing wor ers'' compensation insurancefor my employees. Below is the policy
ir;formotion.
i;:swunce Company Name:_ %x') 011 U'% u A L' 'i--
,/ of Self -ins, Lic. 4: V��/ (�Expiration
> . � � 1 d ''f G l.1 I -.� t7 1 1 Date. �
Site Address: 10 Chu ft"„_Lt s -TT
City/State/Zip:�A(n�� _
altaCh a copy of the workers' compelation policy declaration puge (showing the policy number and espi,.iuun ti.I�"
allure to secure coverage as required u' der Section 25A of MGL c. 152 can lead to the imposition of criminal pcnaltic> o:..
...:c up to $1,500.00 and/or one-year an risonment, as well as civil penalties in the form of a STOP WORK ORDER and
o to $350.00 a day against the viola.:r. Be advised that a copy of this statement may be forwarded to the Office o
estigations of the DIA for insurance I overage verification,
i do hereby certify under the pains andenalties of perjury that the information provided above is true rind currecr.
—
OVIcial use only. Do not write in tits area, to be completed by city or town official.
City or Town:
issuing Authority (circle one):
Permit/License
1. Board of Health 2. Building Del, irtment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
G. Other
Contact Person:
Phone 0: