2 FLYING CLOUD LN - BUILDING INSPECTION 1
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
�J Massachusetts State Building Code, 780 CMR, 7'a edition
�t� Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Ttco-Fmn+h Dmrlling
This Section For Official Use Only
�— Building Permit Number Date Applied:
g
Si nature: \
Budding Commissioner/In rotor f Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Ca m C,
I.I a Is this an accepte street:'yes iG no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(fl)
I.S Building Setbacks(ft)
Front Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
2 1�Qwner'of J/tgcord: / ( _ n
�F[ �� �c�vC �t
Name(Print) Ass for S mice:
c7g -744 (S0 (,67
Signature Telephone
_ SECTION l: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction Existing Building 16 1 Owner-Occupied ❑ 1 Repairs(s) Or Alteration(s) ❑ Addition Cl
Demolition Accessory Bldg. O 1 Number of Units Other ❑ Specify: Co J
Brief Description of Proposed W '•
//I S C✓q O ✓'t..r�— ✓'E G I✓S Q.n
-^ f. ems✓ ew.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item (Labor
Costs: Official Use Only
Labor and Materials
I. Building f I. Building Permit Fee: f Indicate how fee is determined:
Cl Standard City/Town Application Fee
2. Electrical f r
❑Total Project Cost (Item 6)x multiplier / x
J. Plumbing S 2. Other Fees: f 11
4. .Mechanical (HVAC) S List: �
5 Mechanical (Fire S Total All Fees: S
Su ression
0` Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: f �O�.�� ❑ Paid in Full ❑Outstanding Balance Due:
AA�l t11 Cam JVc
SECTIONS: CONSTRUCTION SERVICES
5.1 Licetnssled Construction Supervisor ICSL) CZS YdV&FL4J.
p
'' . f'" t,.�nS G ,,,t Liccnx Numtrcr —E uauon ate
Nilme of - HylJer I�r L Lut CSL Type Bce below)
Description
A PDResidentiall
rmled u to 35.OW Cu. Ft.)
ted 1&2 FamilyDwellm
ure Mason—
RCOnl
r
nnal Raofin Covenn
Telephone 1 ntial Window and Sidin
ntial Sobd Fuel Burnin A liance Installation
Demolition
5.2 Regbt 0 Home Imp e�m'gpt Co tractor(HIC) It z
F n. a^
HIC l gipaoy-Nam or HICI isI ine ram N ) _(� Registration Number
65
Addre -1 ( (4.3ct 0040 -Expiration Date
Signa rc Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 .......... O No...........
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Si nature of Owner - Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si ned under the pains and penalties of perjury
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 Home Improvement Contractor(HIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/porches
Ty pe of cooling system Enclosed Open
t. "Total Project Square Footage"may he substituted for 'Total Project Cost"
t
CITY OF SALLM
Iw3 PUBLIC PROPRERTY
�.,.,. . DEPARTMENT
_- III "A 'J: # I %x b"tl V: ',,1,.
Construction Debris Disposal AflidaOt
(required Iilr all dcmulition iuld renocatiun work)
In accurdance %%ilh the sixth edition ofthe State Building Code, 780 CA I section 11 L5
Debris, and the provisions uf.blGL c 40, S 54:
Building Permit it is issued with the condition that the debris resulting from
this work shall he di.sposcd of in a pruperly licensed waste disposal facility as defined by MGL c
It1. S 150A.
will be transported b :
The debris ( y
(name ul hauler)
I he debris will be disposed ufin
(n�lnr ul Ixl Ily)
1•u ldre,. „1 gclhlvl
.,pnalw/d panel .q+plli.Inl
—r ,Ili
CITY OF SM.EM, UxSSACHUSETI'S
BUILDING DEPARTSIENT
a,,, 1'20'\/ASHINGTON STREET: San FLOOR
TEL (971) 745-9595
F%x(971n 740-9846
KI.,C3U"Y DRISCOLL
MAYORTIiOhW ST.PffJUts
DIRECTOR OF PL SLIC PROPERTY/SCQDING CO%L%rtSSI0%ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electr(clans/Ptumbers
Anolicant Information Please Print Letibly
Naind (Busitwv.Organtrarion,InLhv,dual):
Address: / ( S J ✓S e 4—
City/Stat ip: ,dtrLV Phone#: -M G 4 DOSa
,\re y ao employer?Check the appropriate boa: Type of project(required):
1. 1 am a employer with 4. ❑ I am a general contractor and 1 6. Q New construction
employees(full and/or part-time).• have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet: 7. Q Remodeling
;hip and have no employees These sub-contractors have {. �Dernolition
Workingfor me in an capacity. workers'comp.insurance
Y P tY• 9. Q building addition
[No workers'comp. insurance S. ❑ We are a corporation and its
required.) otYlcers have exercised their 10.0 Electrical repairs or additions
3.El am a homeowner doing all work right of exemption per MOIL I I.Q Plumbing repairs or additions
myself.[Na workers'comp. c- 152,41(41 and we have no 12.Q Roof repairs
insurance required.) t :mpfoyccs.(No workers'
I3.❑Otha c�_S '
comp. insurance tequired.J
-Any appacaet tma chain boa at mual alga Ito tau the secliaa boles sbawing their wrkm'eonwm urim policy inliMmoaeooa
't 6v,wu%mns who submit Mir anldsrk indicating day are doing all work arse than him a midi contractors~"ismit a new alt1devie indicating wck
i',x,trawre I hat.h+ k thin ban mud aaached an sh nanal dust showing use nine of tM aoli cam sectors and thrk when'comp.poicy ink rmauw.
l ass an etnpleyer dti r Is pravidlaX workers'compentradra lnsarome for sty employers. Below/s rbr pellry and foI slag
injormwion. �-
Insurance Company Name: t Q esc c-
Pal icy N or Self-ins. Lic.N:G)C-L 1 n 4 *7�O0 / Expiration Date:,`—e'" /( aOLO
t
Job Sire Address: '.2-- 41-j c �r�-r q "".' City/StatdZip: Sw er�t
Attack a copy of the worker compensation policy declaration pap(skewing the policy number and expiradom date)6
Failure to wcure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of■
f ne up to S 1,300.00 and/or one-year imprisonment.as wall as civil penalties in the farm of a STOP WORK ORDER and a find
of up to 5230.00 a Jay against the violator. Ile advimad that a copy of this statemem maybe forwarded to the Orrice of
Investtgutiuna ql floe DIA for insurance coverage veriticatiun.
/de hereby ra r prin.r mood pena/dis o/perjury that the i"formador provided above is true and Garret.
�n ut ra err rh
f/L—lit.tr'� Dula: ::t—T d ri
Pt ore s
Ofcial axe a,dy Da not wrire in M&area, to be,umpleted by city or town,,1fi-imi i
City or ruwn:
Issuing.%utharily (circle unc):
I. Ituurd of Ileallh 2. 9uilding Department 1. Ciiyrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
l„nlact Person: _ - __. _..--. Phoned: