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23 FELT ST - BUILDING PERMIT APP (002) _ a (( �, The C'onnnomvealth oFMassachuuus Board of Building Regulations and Standards CI'I'1' OF Massachusetts State Building Code, 780 CNIR Building Permit Application 'ro Construct. Repair. Renovate Or •mulish One-or Tmw-Funnily Du eflo,k, This Section For Official Usc Only Building Permit Number: Date, p lied: 1,;44o.tls� L7ZZ ( Building 011icial(Print Mane) Si Du e SECTION I:SITE INFORMATION t.l Property Addres f�T 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an acce ted street?)n X no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Arco IN It) Frontage(11) 1.5 Building Setbacks lift) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.c.JU.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Munici el❑ On site disposal Chock il' es❑ P posal s stem ❑ SECTION2: PROPERTY OWNERSHIP 2.1 .Ow2ert of Reco LP_i/.7 h . cal/H •�.S JA Name(Pri ice/ Jn24 City.State,ZIP relephune kmuil Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alleration(s) Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief DescriptionFfPropused Work : SECTION a: ESTIMATED CONSTRUCTION COSTS Itcm Estimated Costs: ILabor and Materials) Official Use Only I. Building S 1. Building Permit Fee: f Indicate how fee is determined: 2. Electrical S ❑Standard CityrTown Application Fee ❑Total Project Cost'(Item 6)x multiplier l ). I'lumhiog S 2. Other Fees: S — - -- — J. Mcdtanic,d i11\'.W) S List: ' S. .\Iechanicul iFirt - ---- -------- -- - -- . . . . — ---' — — Su t ucssion l rotal All Fees: d 0 Ch"k No. _Check:\rtumnn: _ C,uh \mount: n. Tidal Project Cost: S DO- '— ❑ p;tiJ in Full 13 Outstanding Bul:mcc Due: SE("PIONS: CONS I-RU(-rIONSERVICES 5.1 Construction Supervisor License(CSt.) I icenee Number PSI ratio Uam Nome ol'01. I lulJef o L IisI CSI. I)pe)see p1L� ✓-PP% 1��-----`--'-- Description No_and Street A U UnrcslriaeJ UluilJin's ti 10 15,111111 eu. It L/1111Lh ✓ail S ._�/ R Ncntrirl.J I l21vmil bttcllin Cilti l'o+s n.Slate.%II' %I %lasun I(C It+K+1in Sin \1'S N'indutr,uid:mJ SiJin SF Solid Fuel Iluming Appliances � // � �(�P� %PC� GJwrp�/iC0✓ft I Insulation 1'ele he onr:u nJJnss D Damolitiun 5.2 Registered Ilome Improvement Contractor(HIC) �dl �o—/ B•-r , S I IIC Itcgt9naion Nunttter Ispira on Dote IIC Contpan) Name or IIC Ire stunt Nam, PN ( / / � �� Q�!l h4 I�..J f�" - IN 0 ✓11 NoA and Street Libuil addres� AH rerr '141 U/92 f399-$S9 s Ci /rown,State,ZIP fele hone SECTION 6:WORKERS'COMPENSA ION INSURANCE AFFIDAVIT(M.G.L,e. I52.1 SSC(6)) Workers Compensation Insurance affdavit 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...........O SECTION 7s: 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 Uwner's Nane(Electronic Signature) Date SECTION 7b:OWNERI 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 Owner's or.\ulhuriieJ Agent's Name(lileclrunic Signaura) Data NOTES: 71notregistered r who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor stered in the Home ImpruvententContractur(HICI Program),willnrr have access to the arbitration or guaranty fund under M.G.L.c. 11_'A.Other important information on the HIC Program can be found at •. + , t n Information on the Construction Supervisor License can be found at +>t+t ul.n;�: t 'Ih. bstantial Iwrk is planned,proside the information below: ea Isy. fl.l - including garage, finished basement attics,decks or porch) Grois liking area l sy. 11.1 _---. Habitable room count I Number olfireplaces .... Numberol'bedrooms \o mlivr of bathrooms . . - Manlier ul'half haul's h pc of hcoting sy stem \umber ofdecks, porches IU I 1 n pC PI e+4+1111g i\ilelll 1'I1elased (l t•1 I 1. "lolal Protect Square Footage"nl;t) he substinucd Ilrr..1'olai Project Cost- 1 crry OF S:uE.N.[, NWSACHl;SETTS \f� BUILDING DEP.IRTMFNT 120 W-ASHLNGTON STREET 3'a FLOOR �. TEL (979) 745-9595 F.kx(978) 7 0-9846 U>l13EILL.EY DRISCOLL AMR. T HOstAi ST.PIEM DMECTOR OF PCOLIC PROPERTY/BUILDING CO\I]MtlSSIONER 1Vorkers' Compensation Insurance AtTldavit: Builders/ContructorsjElectricians/Plumberi 1- Apollcant information Plea4e Print Lenihly �I;IInC lnmitxss,UrWrmratirnlndividual): /�•/N ,,L� r c.-&Y l r�C' Address:-/n/ /L �� I'7f�8�. / /7✓e v City/State/Zip:6/1N ✓e .*-.r OTT PhoneN:_l�/ \rc you an employer?Check the appropriate box: 'Type of protect(required): 1.0 1 am a employer with 4, 0 I am a general contractor and 1 6, 0 Now construction �loyees(floli and/or part-time).* have hired the sub-contractors; 1. I am a sole proprietor or partner. listed on the attached sheet : 7•�emodeiing ship and have no employees These sub-contractors have V. 0 Demolition working tier me in any capacity. workers'camp.insurance, y, 13uildine addition (No workers',comp.insurance 5. 0 We are a corporation and its squired.) officers have exercised their 10.C1 Electrical repairs or additions )•❑ 1 ran a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or udditionst myself.(No workers'Gump. C. 152,41(4),and we have no 12 0 Roof repairs insurance required.)t employees.[No workers' 13,(�other comp.insurance required.) •,%ny applk:vn dW vltmkt but rl moss also,all out the wuliat below showing chair"ton,compensation policy inM1umallon. 'I hmwuwmtn who whmil this a@Idova indicating they am doing all work and then him wields contncton moms mhmit s raw anWavit ioditming ruck :("'no M' '10n thtl uhcsk this bus mina an.xhod an nddiaoaud.hw o ihuwing the roarer of the mbcernlmhae and thelr woAcre'stamp.policy inramuame. fain ten ruipluyer thut ly pruvidlnX workers'c omprnsatlon Inrurence for my employers: Below/s rise Polley and job Woe infurartnlon. Insurulee Company Name: Irolicy 4 or Self•ins. Liu, 4: - Expiration Date: Job Site Address: - City/Slate/Zip: .wsh s copy of the workers'compensation policy declaration page(showing the policy number and axplrettlon data). F.liluru to sceuru coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ora tiro up to 51,500.00 and/ur one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a line of up to 5130.00 s Jay against the violator. Re advised that i copy of this.,tawinunt may br furwardcd to the 011ica of Inve,li gal iuns of doe MA lorinsurmsc covemgo vcrilicaliun. /da hereby 4 rritry 11 -N a"Is mad penalties of perjury ill l the iufurnlutlwr provided abuvir iv true widcc•orrect. Day rOfficialu,eanly. Oo not write in this urea,m be cumplered by city or town njjy /at or l'nwn:nK,\ulhurily (circle una):urd ofllcallh 1. lluildln�I)eparnneut 1. Cityirnovn Clerk J. Eleetrlc.d ('t'pcclor i. Plumbing f lipeetdr 11cr Cnnlacf I'craur CITY OF S,U-&Ni, Aus,kCHt:sETTS ia ©C[LDLVG DEP.IATtEVT 120 %V.I.iH6VGT0N STRART. Jw FLOOR ILL (978) 743•959S KI1®ERLBY OAMOLL FAX(978) 740-984 .tiE1Y01! TRo..%WST.PM A D ixo=o It OP PL BLlC PROPERTY/SL•p p LvO CO.%OIIS1to.N Eft Construction Debris Disposal At'ildavit (required for all demolition and renovation work) In accordance with the sixth edition of the state Building Code, 780 CM Debris, and the provisions of MOL a 40, s 14; R section I 11.J Building permit M is issued with the condition that the debris resulting from this work shah be disposed of in a properly licensed waste disposal facility as defincd by NIGL c 111, S I JOA. � The debris will be transported by: (n,una of hauler) TTh�e�debris will be disposed of in : / (noma oY facdi�y) ❑yn�mro ofpermit �ppbu