20 CRESCENT DR - BUILDING PERMIT APP (002) .� The Coinniomvealth of Massachusetts
Board of Building Regulations and Standards CfrY OF
Massachusetts State Building Code, 730 CMR SALEM
a Revised Mar 201
xuI Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only.
Building Permit Numbery Dat Applied>
Building Official(Print Name) +. Signature / Date
SECTION 1:SITE INFORMATION
1.1 Pr pe ty�dress: �/�, 1.2 Assessors Map& Parcel Numbers
1.la 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(sit ft) Frontage(It)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2, PROPERTY'OWNERSIiIPL
2.1 Ownert of Record:
C ;;2 l_ �, Cb vj SIA
Name(Print) City,State,ZIP
�zd CiCl < C.e -, 't Dr-
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessary Bldg. Cl Number of Units Other ❑ Specify:
Brief Description of Proposed Work': C n vJ jf�
-�s�to QC�v_\ � _ o, « .
icPwcE a fa=)a 2 P1�1
'a s�n(z0a-c7
SECTION 4: ESTLYL4TED CONSTRUCTION COSTS
(rem Estimated Costs:
Labor and Materials Official Use Only,
1. Building j I. Building Permit Fee:$ ` Indicate how fee is determined:
1. Glectricd 5 cr Standard,.Citylrown Application Fee
❑ rotai Project Cost'(Item 6)x multiplier x
3. Plumbing i 2. Other Fees: 3
1. ,Mechanical (1IVAQ S List:_
3. ,Mcchafical (Fire -
5i , ucssiun)_-- I Total All Fees:.i_
I'ntal Project ('u:L i (Cj CX�
W Check No. Cheek \nwunC Cash Amuuut
❑ Pail io Pull Cl Outstanding Kll:,nce I)uc
SEC'r(ON 5: CONSTRUCTION SERVICES
5.1 Cottstrrrclion Supervisor License(CSL) p
i7 - ipO
rl� Q 1 License Number Esp tniot atc
Namc�ot'CSL I IuAlar 1—_ e List CSL rype(sce below)
re�.� > Description
No. and Street Unrestricted Ouildinos u to 35,000 cu. Q.
R Restricted1&2P;uni1 Dwcllin
city/roi n, State, ZIP VI Masonr
RC Root-in Covering
WS Window and Siding
SF Solid Feet [Turning Appliances
( Insulation
l'cle hone Email address D Demolition
5.2 RegistPreduHomeImprovementContractor(IIIC) � -7
2 d k7 e [l[C Registration Number Expiation Date
I TIC oinpany Name or HIC c istraut
No�wd Stree(. r7 �"'(� '��(
Email address
_� X
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 DE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
[,-as Owner of the subject property, hereby authorize 7' — gooK�
to act on my behalf, in all matters relative to work authorized by this building permit application.
/i 1 Q QOz S I I
Print Owner's Name(Electronic Signature) Date
SF.CT[ON 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 application is true and accurate to the best of my knowledge and understanding.
-------------------
Print o�-Inlr')Or Antl10rlZCd:\grays Name(Electronic Signature) D,ue
NOTES:
I. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(nut registered in the Houle Improvement Contractor(HIC) Program), will Lint have access to the arbitration
program or guaranty fund under M.G.L. c. 1.12A. Other important information on the HIC Prograni can be tound at
aww m;us.�udoea Information on the Construction Supervisor License can be round at ww,v.mass.•w�'dL;
2 When substantial work is planned,provide the information below:
1'util fluor area(sq. (I,) (including garage, tinislied basement/attics, decks or porch)
tiros; living mca(sq. It,) _-- — f l ibittblo rouul count _--
Nund�cr of lireplaccs-._ ------ Number of bedrooms
---- --
Vumhcrotb.nhrooms
I\pcothc.uing ;yucnt Numberotdecks/ porchas _--_--
' I�,pe ,Fco,,lin•� wacitl I?nclo;ed P ... _. _ -- -- - ...
t l ell
i. '-I',u.11 r �i a �lµl.u.: Foot nary be ,ilh:titul. I [111 '��1.11 I'101iCLI l O, C --
Massachusetts -Department of Public Safety
Board of Building Regulations and standards,
Cnostruction Supenunr
License: CS-059800 i
+ +.
IEFFREY T B000, �
85 GRANITE 5[; Z�
FOXBORO MA 02035,
e
c
Expiration
a 06/18/2014
commissioner
R
,per ' a l p((pr�y,p'Bltsroess negate tlo
ate` M' r
' HOME IMPR+)VEMF�C'11~1C
�
te9lstretion128908 r
Individu I i
ExplratloriT 55I9I�Ot37 �� c
c $ �
JE RWT BOOh���z7i
+ K SSGRANITEST
1� ,, FOXBORO MA 020351� _� Undersecrel+ryi
I
CITY of 5:
Y 1LEltil, jANL1S5.1CHUSETi'S
BL=LNGDEP.1RT1lEaNT
1'0 Cf/."
HLYGTON STREET, } FLOOR
TEL (978) 745-9595
f<1J[3ERLEY D[t1SCOLL
F.LX(978) 7-W-93.15
INILkyolt T 10nusT.P1F.RltB
DIRECTOR OF PL'13L1C PROPERTY/aLU-OLNG CONOUS51O.NER
Construction Debris Disposal Afttdavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 730 Ch1R Section l 11.5
Debris, and the provisions of I&1GL a 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 tbdGL c
111, S 150A.
The debris will be transported by:
hw55aa-t�iE,,--n w�s�
(name orhauicr)
The debris will be disposed of in
(name of racaity)
(address or(aaility)
s na it or crmitappticant
,Luc
I
° QTY OF S:U.E1,I ANSSACHUSETTS
+ 13ULLDING DEPARTMENT
120 WASHINIGTON STREET, 3sD Root
wee c T EL (978)745-9595
P.L'c(973) 140-9846
KIND Rf RY DRlSC011.
NLiLY01 T Ho.%Lu ST.PIERR8
DIRECTOR OF PUBLIC PROPERTY/BUB-D[21G CO\pIISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applleant information \/ I— Please Print Leeiibh
Nanic(Busil%ssorganirutiurvindividual): J Q 'S �r' 2--r
Address: S 1
City/State/Zip: —Gh �J D a Phone N:
Are you an umployer?Check the appropriate box: 'rype of project(required):
1.❑ I am a employer with 4. ❑ 1 are a general contractor and 1 B. ❑New construction
employees(11611 and/or part-time).• have hired the sub-uontnctars
2. 1 am a sale proprietor or partner. listed on the attached shout t ?./EfRemadeling
ship and have no employees These sub•conlracton have a. (]Demolition
working for me In any capacity. workers'camp.insurance. 9. Building addition
(No workers'comp.insurance 5. C] We are a corporation and its
rcquirud,) ofRcen have exercised their 10.C]Electrical repairs or additions
3.0 1 am a homcuwncrdoing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'cump. C. 152,Q 1(4),and we have no 12.C]Roof rupaira
insurance required.) t umplayees.(No workers'
comp.insurance requirod.j t].❑Other
•Any applle:ue dw chceks box el must also elt out the scctiue below ahowing that,wakaw'erompmudon policy infurmaaon.
'I hunuuwm"who sulmdl Nis airdavit indicming they ar•doing ell work and slits hln outside contraetas trial submit a rtew airdavil tndicatlne such
C,tntrnuton that check this box mint auachod an additlunul,hocl showing tho name of tee ntb:t'0mnabna and Iheb workm'ramp.policy infumadon.
lain an employer rbaNs provldln)<Ivorkas'campwrradon luraronee jar my empluyerx Below Is the pallcy and Job site
injarrnallurt,
Insurance Company Name:
Policy R or Sclf•ins.Lic.n: Expiration Data:
)ub Site Addruss: City/Slate/2ip:
Aeach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to sccura coverage as required under Suction 29A of,%,iGL c. 152 can lead to the imposition of criminal penalties of a
Pine up to S1,500.00 antVar one-year imprisonment,as well as civil penalties in(he tarn of a STOP WORK ORDER and a line
of up to 5250.00 a duy against ilia violator. Ile advised that a copy of this.rtatument may ba rorwurdcd to the Ohms of
Invcsligaliwts of the DIA rat insuranca coverage verification.
/do Ir.ereby ter hider fire lily and penulNr pry Careu / ju sunt
o ,1•
i 011fciul use only. Oo oat 1wile in ride arra,to boa runrplNad by city ur to suer,tJJh•!ut
I
Citynr'I'uwn: _ PcrmfUL)ccmc,e
Iesubag Atilhurily (circle one):
1. ❑ourd of Ilcullh Z. Iluildlm2 Oeparhnmtt .1.Citylfown Clerk 1. Electrical Inipectur 5. Pluntbin4Inspector
6. Other
Contact l'ersno: _ _. ._ Phana%!: i