22 FOREST AVE - BUILDING INSPECTION (2) ,l� — --- I'heC'onunonwcatllh t t ' . ._,tes. .
1 Mtvhuults
f \I u it '� Board of Building Regulations and Standards CITY OF
W 'r Milssachusetts State Building Cudc. 780 CMR SALG\I
1111JJJJJJJJ 'L"•' R"rixrJ llar!ll//
Building Permit ii,wic tion 'ro Construct, Repair, Renovate Or Demolis
One-or Ttcn-!o n li Dialling
rhis Section For 013i No
I Use Onl
Building Permit Number: Date
d"JA,pp�lied.
Iluilding Oliicial(Print Munc) Signature , Date
SECTION I:SITE INFORMATION
1.1 Pro�serty Address: 6I Assessors Map& Parcel Numbers
a -rosRLST Ave
I.la Is this an acre .ed street?yes no Map Numher Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Pmposcd 010 Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yana Side Yards Rear Yard
Required Provided RequiredProvided Required Provided
1.6 Water Supply:(M.G.I.c.qo,§N) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munici el❑ On site dis )
Check,,- -- P pusol s-stem 0
SECTION I., PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Marc(Print) City.State.ZIP
�2• ��r sr �7L )41-3703
Nu.;mJ Steel Telephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alterallon(s) ❑ Addition ❑
Demolition ❑ .accessory Bldg.❑ Number of Units_ Other ❑ Spccily:
Brief Description of Proposed Work': GIZACAA IRAID I-LDO
577?i�CS . r�rz/ifl.STiFI_t /LvRBfd2 A00F eAJ LA-ISUAI`6 Ax5#4<
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor Bard Materials) OMclal Use Only
I. Building f 1. Building permit Fee: f Indicate how fee is determined:
'. Electrical - f ❑Standard CityiTown Application Fee
❑Total Project Cost't Item P 6)x multiplier _ x
i, I'lumhing f 2. Other Fees: f
J. Mcchanical III\ W) S List:
5. \Icrltanieal tFirc —_— -- �
Su +ression) S rotal All Fees: f —
Total Project Cost: S 7 D Oo , o D C'hcck No. _-_--('heck Amount: l',uh \mount
❑Paid iti Full ❑Outstanding Bahince Due:
� ' ( � oc/
SECTION S: CONS'1'RUC'fION SERVIC'FS �7
5.1 C'unstruction Supcnisor License(('SL) Q qrs 5 _ �__�-( -tZ
- icense Numhcr I'Npir lion Date
N:one ut'C'SL I�'Act
2
77J C q -_-__--57 , — 1)Pe Description
Nu. and Street
U I hlrestrded I UuilJin�s uJP nl 15,(1(I0 cat. I11
R Itcnlricicd I&I F.unil 1 lAwilin
t'II\i town.State.41 SI Masan
ry
RC 19 Covcrin
WS Window arid Siding
ap
SF Solid Fucl Burning Appliances
7eq S3�-hM I Insulation
I'ele hollu E:nlail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
AzI
g/nytp �"d / D't ODA6 • IIIC'Registration Number Espnntion Date
IIIC'Cnmpunj N IIC'lemma an>v— iJZy))jdCuA] tTlQeTioN
No. ; tract L..mull address
6 tQ . 0196o I�s'3d �8� U �zon . nL �
City/Town.State,ZIP rate hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atfidavit will result in the denial of the IssuancF of the building permit.
Signed Affidavit Attached? Yes ..........e No......,....O
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.
Print Uwner's Nume(Electronic Signature) Date
SECTION 7b:OWNER' 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 best of n kalliwledge and understanding.
Trial Owncr'.tor:\uthuriied,\gent'sM umc(Electrunic.'ign;nurcl Date
VOTES:
L An Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered cuntractor
(nut registered in the Hume Improvement Cuntractor I HIC)Program),will tro have access to the arbitration
program or guaranty fund under.M.G.L.c. 142A.Other important information an the HIC Program can be found at
www m,r.. AA Information on the Construction Supervisor License can be found at
v1'hen substantial work is planned,provide the information below;
rota) lioor area Isy, R.) _ ____-._I including garage, finished bascnlcnCattics,decks or porch)
Gross living area Isy. 11.1 .___. - Habitable room count .-
Nlmuberoffireplaccs ._. .. _ Numberoftledroomis
\umber of hadlromns Number ul half hall's
I)pe al healing system Numhcr of decks, porches
I!IleldiCd
Open
� l v pe. 1 ettth llg i\51C111 _
t. "I*,dal Project Square Fool.lec-Ilia) he sobintuted lLf-I"otal Project Cost- �
CI-I•Y OF SUE-Nis NWSACHUSE"ITS
OL'IL OiNG DEPART LENT
120 WASHLNGTON STREET, 3'a FLOOR
TEL (978) 745-9595
Fla(978) 740.9846
Kj 113ERLEY DRISCOL L
�UYO.q THstA Os ST.PIEUS
DIRECTOR GF PUBLIC PROPERTY/BUMDLNG CON6IISS ION ER
Workers' Compensation Insurance Affidavit: Builders/Contractorv/Electricians/Plumbers
Applicant Infarm•rtinn Ptease Print LePihly
/1 r—
V(IIflQIBwilx..oUrganiratianrindividu/d I)� �r'/�"' �elucll . l�I�• -�IU � .
Address: 3 3 �iAJ�l7ZtAL .ST- cy
City/State/Zip: 1A fi 0 W Phone N:_ t
Are ytl employer?Check th appropriate box: 'Type of project(required):
I. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
antpinycea(full and/or part-time)." have hired the sub-c:oniractors
2.❑ I am a sole proprietor or partner- Iistad on the attached sheet t 7. CaAe ffa-deling
ship and have no employees These subcontractors have g. ❑Demolition.
working for me in any capacity, workers'comp. insurance. 9, ❑ Building addition
INo workers.comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.1:1 Electrical repairs or additions
J.❑ 1 am a homeowner doing all work right of exemption per MGL I I CI Plumbing repairs or additions
myself.(No workers'sump. C. 152,11(4),and we have no 12 04ttfoP repairs
insurance required.) t employees. (No workers' U.❑Other
comp.insurance requirud.j
•Any applicml raw vhn<ks boa rl must also rill out thv wclim below showing(hair wotken'compsnwdun puliuy noinmalion.
I fi-uownen who submit this amdnvil indicating they an doing all work and then him outride contractors must submit a new ullidaril indicting suclu
:C.mlrxwn that chcak Ibis has mull aoubud in addiiiutwl.halo shuwing the nwne of the t,b.,on:Mt m and their woken'wrap.polity infomudon.
I airs an enspluyrr(hut/s pruvidlaX)vorken'curnpenaatlun insurance for my emplayees. Below is the policy andjob site
iiijonnudnn.
l ,DNS. ✓f
Insurance Company Name: /1 � _._� 1 �i(k �l/' (-C S -7-/V e
Policy N or Self--inn. Lie. N: 6 1 �xp>'�tion Date:... �-�D '- 1 2
Job Site Address: Z 2 Fa"�57 I City/Slate/Zip: .
Attach a copy of the worker' compensation policy declaration page(showing the policy number and expiration data).
F-ailuris to iccurc coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
rine tip to S1,500.00 and/or one-year imprisonment,as well as civil penalties in(he form of STOP WORK ORDER and a line
of up to S230.(10 a day against the violamr. Re advised that a copy of this.statement may ba furwirdcd to the Ol lice of
Ina estigitiunsol'lhe OIA I-or insurance coverage •rilicaiion.
1,10 hereb certif it r th t pen f of perjury that the Ltfurinu(lurr provided above i.r irue and correct
1 II
rh,i ;1 � • S3a - �
U!licial ti.0 only. no nut rvrite in Mix area, to be cunrplet!d by city of fit o�JiriaL
Cif v1'owu: a,
y' — . - __. l rrmiuT.lcense 47, o
I+suing,\Wburily (circid unc):I. Buard of Ilcallh 2. ❑uilding Mpartiuent 1.City(Town C'terk 4. F.Ieetric.11 lnrpector 5
6.Other
i
Contact Verson: ,
j - ihonc%1: __
i -
Information and Instructions
>lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract orbits,
cypress or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings In the commenwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally, MGL chapter 152, §25C(7)stales"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)nume(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on rile for future permits or licenses. A new affidavit must be filled out each
year. Where a(tome owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
the Department's address,telephone and Fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Wee of Iavestigations
600 Washington Street
Boston, MA 02111
Tel. 4 617-727-4900 ext 406 or I-877-MASSAFE
Fax M 617-727-7749
Rcv.scd 5-26-05
www.mass.gov/din
CITY OF S.UzNf, >tiLtss:kcuus&rTs
9LdDLYG OEP-imu Nr
120 W.IUHLVGTON STIM, Jw FLOOR
TtRL. (973) 745-9s9S
K1303ERI Y OUXOLL FAX(978) 740.9&W
MAYOR THoswST.PmE n
DtRECTO11OPPLBUCPKOPER Y/BCQALNGCONOUSSIONEft
Construction Debris Disposal Atttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CUR section I 11.S
Debris, and the provisions of MOL o 40, S 34;
Building permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a proper
I 11. S I SOA. ly licensed waste disposal facility as defincd by NIGL c
The debris will be transportcd by:
(name of hauler)
,T^he1 debris will be disposed Orin :
G-
(name of facility) �—'
�4-L-&at, VM
(Admi of f�cditY)
1
114"ru4amml,
PP .nr