6 FLYING CLOUD LN - BUILDING INSPECTION � I
The Commonwealth of Massachusetts
Board of Building Regulations and Standards *0000dow
�— Massachusetts Slate Building Code, 780 CMR, 7'"edition
BuildingDept
Building Permit Application To Construct, Repair, Renovate Or Demolish
One-or Tern-Fumih Duelling
This Section For Official Use Only
Building Permit Num r. Date Applied:
Signature:
Budding Commissioner/fnspco&ti Buildings Date
SECTION 1:SITE INFORMATION
1.1 Prop e Addre au // 1.2 Assessors Map& Parcel Numbers
Cn
1.1 a Is this an accepted street'!yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Disinct Proposed Use Lot Area(sq fl) Frontage(fl)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,S54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P pO y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own e of Record,
Name(Print) Address for Service:
97&- 7q L9
Signature Telephone -
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other O Specify:
Brief De ription of Proposed V)C9 k':
l'r
� � q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building f 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical f
❑Total Project Cost to 6)x multiplier x
J. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List: /
5 Mechanical (Fire S
Su ression Total All Fees: S
��y� d J Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: SL �". 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) �7 S ,E d-( a Cf
'' .mlitt'- Co'sc-Vk,"L L.cen.w N•umbcr Eapuunon Date
N;tme oI iy
� ..�Ider List CSL Type Ixe below)
a --� Description
Addresstie1 Unrestricted(up to 35.000 Cu. Ft.)
R Restricted Ik2 Family DwelLn
Sign r ( 11 Nlascmry Only
RC Residential Roofing Covering
Telephone r wS Residential Window and Siding
��� � SF Residential Solid Fuel Burning Appliance Installation
l9 D Residential Demolition
5.2 Registered e omelmnSKemeGn Contractor(HIC)rvulc- 0 f'O-D 7
HIC Company-Name or HIC R 's rant Narr)e, t RRegistrauonn Number
A NICIS f(��F� 1
05c -QrJ...� U i6ration Date
g re 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.......... 0 No...........❑
SECTION 7s: 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.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and iccurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
1. 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 6A 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 l0.R6 and I I0.R5, respectively.
EWhen substantial work is planned,provide the information below:rs area(Sq. FL) - (including garage, finished basement/attics. decks or porch)
g area(Sq. FL) Habitable room count
f fireplaces Number of bedrooms
f bathrooms Number of half.,baths
ating system Number of decks/porches
oling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"
CITY OF IALEI , �rLXSSACHL:SETTS
BL'QDLN(;DEPAR-MEINT
F 120 W.%SHINGTON STREET, Jia•FLOOII
T L (978) 74S-9S9S
F.%x(978) 740`984
KI-,BE"y DRISCOLL
MAYOR -ItioatAs ST.PIFJUts
DIRECTOt OF PL SUC PROPERTY/AV DL%IG CONDUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricionslPlumbers
1pnllcant Information Please Print Legibly
Name jausirn Organoaation•Indav,dualY �/["'r—L L.a9•�-Svc a�V-7
Address: IIq; �(_ e�'S, f
City/StatdZip:4A " w"��� �`t Phone N: 7�j (0sS C) CJ
Are yo employer!Check the appropriate box: Type of project(requlrecO:
I. 1 am a employer with a. 0 I am a gcna'tal contractor and 1
e have hired the sub-contractors 6. ❑New construction
employees(full and/or part-time). 7 Remudelin
2.0 1 am a sole pmprietar err ptartner- listed on the attached aheeL: . g
,hip and have no employees Theca sub-contractps have S. Q-P3"emolition
workingfor me in an capacity. workers'comp.insurance,
Y P tY• 9. 0 Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself[%o workers'comp. c. 152.410),and we have no 12.0 Roof repo' 1
insurance required.) r employee. [No workers' 13.0 OtherR`�P
comp instuarmtequimd-1
-Any upplicasa tltr aitaeh Iq1 al mum 9"tin UUI lira sachem below abowity their workers'eanpnrarien policy infumtmlota
'i Itmwownws who suboot ilia affidavit indicating they are doing all work and them him onside couracaors mum submit a Rate anlinvil indiryLq.awk
:C,,ni ators that cluck this bran mum anschod an additional Anot showing On nwne of rho a a► ouamwa and their wurkarr'ra T.policy infarnotiem.
/am aw etwp/oyn that b provid/n�worAtrs'eotwpetnsatba InswtvEreeJor Ewy etwplayees Below/s/lot policy ead/ai slle
information. //(��
Insurance Company Name:'" `' roC_
Policy N or Seif-ion. Lie.H:W� S c2 y y L,f Expiration Date-)' "t` t[ �`y ( O
r•fob Sire Address: Ciry/SraldZip: �),kJCZ4,t $ ,4 _
Attack a copy of the workers'60peltitstiom Polley declaratlon page(showing the policy number and expiration dots).
Failure to secure coverage as required under Section 25A of MGL c. 132 can lead to the imposition of criminal penalties of a
fine all to 51.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a ring
Of up to$230,001 day against the violator. Ile advistxl that a copy of this statement maybe rurwarded to the Office of
Invcangationa of ilie MA for insurance coverage verification. -
/do hereby cerp&u4ider the pains and penalties of perjury that the informatlow provided above is t ere and carnet
d
\n•Ilyure' ^—`�V \ vv Dale.
P`nrc ,i 71�>I. � S C7CJd
Dfaial sae only. Do not write in this area, to be,ump/eted by city or town b/Jl,.iRI
City or ruwn: Ycrmit/1.1cense0__
Issuing.\uthunty (circleone):
I. Ituard of Ileallh 2. Building Department .l. City/rown Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
l..talact Pcrion: _ ._. -_ .Phone N:
y CITY OF SALLM
;. I;4 PUBLIC. PROPRERTY
DEPARTMENT
__ III ' 'V.•1�. :. : � I �� '�'.V V: '.i L.
Construction Debris Disposal Aflidasit
(rcyuircd lbr all demolition and renovation \vurk)
In accordance \1 iIll dlc sixth edition of*the State Building Code, 780 CAIR section 1 1 1 S
Dcbi is, and the pros isiuns ut NIGL c 40, S 54;
building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by ,MGL c
I1I. S 150A.
The debris will be transported by:
I name ul hauler)
I he debris will be disposed of'in
(uame tit Iasi ply)
1•1.1dre" ur Acduvl
1
.151141ulc of pinnit .ggilw ant
.life