25 FORRESTER ST - BUILDING INSPECTION t
. �i,l °i �-�. � t�5
,
,� The Commonwealth of Massachusetts �SpE'�r'��Pti✓�' CITY OF
' Board ofBuilding Regulations and Standazds A� j����EM
� �� Massachusetts State Building Code, 780 CMIj�'6 Revisec�Mar 2011
ru ����.�
� Building Permit Application To Construct, Repair,Renovate Or e i � � � ,
� One-or Twa-Family Dwelling
� /� This Section For Official Use Only
V � Building Permit Number:- Date Applied:
�
� Building0fficial(PrintName) � Signature�� Date '
�
� 4 " ' < y SECTION 1:SITE INBORMATION , i
� 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
as Fo��E��-�� �T��r
� l.la Is fltis an accepted sheet?yes_ no Map Number Pazcel Number
1.3 Zoning Informatiou: 1.4 Property Dimensions:
Zoning Distric[ Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yazds Reaz Yazd
Required Provided Required Provided Requiced Provided
1.6 Water Supply: (M.C.L c.4Q§54) 1.7 Flood Zone Intormation: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system �
� CheckifyesO
SECTION 2: PROPERTY OWNERSHIP`
21� Owner�ofRecord: .:- .�..:� :.� .. ..�.. 5' ..�[�'I :... �. �/`a ��� 19 �7b �.
SfeJc �Csrr(-tti C:�/1n., �5 '��!'���7e�,' ��
Name(Pnnt) T—nc— City,State,ZIP
�� r�/rCS}rC'` `,'� Sf3�j S/7 6!/� Cuf�Ph_ �7 '� ' ca �.
No.and Street Telephone Email Address
SECTION 3:DESCRII'TION OF PROPOSED WORK=(check all t6af:apply)
New Construcrion❑ Exis[ing Building❑ Owner-Occupied ❑ Repairs(s) .�° Altetarion(s) ❑ � Addition �❑ �
Demolirion ;� Accessory Bldg. ❑ Number of Units Other ❑ Specify:
BriefDefscriptionofPropos/edWorl�: �cr' ' .'� c , r.n �o$ s-
Ol di c+ �)R ��U�T! 1� �IaU �1- �f 9'f!� �x� �'�_�/'�L �.1 �fY L.
�FGr�� �v1 d ,�s^� �Fz; .��.J }ya.�e.� �-f
SECTION 4:ESTIMATED CONSTRUCTTON COSTS
Item Estimated Costs: Official Use Only,
Labor and Materials
1.Building $ � JJV I. Building Permit Fee: $ Indicate how fee-is de[ermined: ���
2.Electrical g ❑Standazd City/Town Applicarion Fee -�
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (FNAC) $ List:
5.Mechanical (Fire $ ' �
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ � � ❑paid in Full ❑ Outstanding Balance Due:
rlrl !a 6 l.. TUp�CA tJT '�2.
{Y1Q-11 1..�'(� 1 cJ� ' �� 'a.
I
3
SECTIONS: CONSTRUCTIONrSERYICES
__
51 Construchon Supervisor License(CSL) �
. [SCye�� �`� �✓� lO /
\��F(�l�.r/� �'.y�f JJ da�,��� License Number E ira on Date
Name of CSL Holder
List CSL Type(see below)��
�S ��/'���1t�' �fi"
No.and Sheet Type :�Descriprion'
� �"�� '��1�1 �U Unrestricted Buildin s u to 35,000 cu.ft.
-��_.�r=vn. %7 '+�'f�� � . R Restricted 1&2 Famil Dwellin
City/Cown,State,Z� M Maso �
RC Roofin Coverin
WS Window and Sidin
� ` p t SF Solid Fuel Buming Appliances
Fj/�,3�,7�'7 f, nst{�.vt 1 �q?� 1�Cf�P - ,� - I Tnsulation
Tele hone Emaz ad D Demoli[ion
5.2 Registered Home Improvement ConMactor(HIC)
.�I�F,e� � G��a�.ti.�l ��� le� Zq €�2�r��
HIC Registration Number� Expiration Date
C Co�p any Na e or HIC Registrant Name
�•.,,rli°S�! Su� � '�.r✓.z�JD` „
�-� f" �r-;,�.�,,�.( c �,�� ���,
No.and treet � �T Email a dres�
�z�� �� �i9 �7� G�73�?z��� �
Ci /Town,State,ZIP Tele hone �12�N ��{.�l(�l.. �
' SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDA�'IT(M.G.L.c.152.§ 25C(6)) , � p o
Workers Compensation lnsurance affidavit must be completed and submitted with this applicatioa Failure to provide
� this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .........!.Lri No........... ❑
SEGTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize �GF�Q�`i �c�A�A�,��
to act on my behalf,in all matters relative to work authorized by this building permit application.
� - � Ze3l�
P nt wner's Name(Elechonic Signature) Date
SECTION 7b:IOWNER'OR AUTHORIZED AGENT DECI.ARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
wntained in tlus application is true and accurate to the best of my knowledge and understanding.
cl�-���E`� (-��A�IR�r�/L�� �/S�' ��a
Print Owaer's or Auth - ed Age¢t's Name(Electronic Signature) Date
.. _. ._.__. . ._.. .. ... .. .. . . ... ..... .. ..._.. .. .__.. . . .. . .._ __.. . . . . . . . .. .
`NOTES:
L An Owner who obtains a building pernut to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Lnprovement Contractor(HIC)Program),will not have access to the azbitration
program or guazanty fund under M.G.L.c. 142A.Other impor[ant information on the HIC Program can be found at
www.mass.gov/oca Infoimation on the Coastruction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor azea(sq.ft.) (including garage,finished basemenUattics,decks or porch)
Gross living azea(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Squaze Footage"may be subsrituted for"Total Project Cosf'
� The Commonwealth ofMassachusetts
� Department of Industrial Accidents
� Office of Investigations
� 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblv
N3ri10 (Business/Organization/Individual): , 1'f�( '1"—Q���C�'��� �(�J
Address: `�� I' r/�.►�SI����— ��
City/State/Zip: �,���n . d' 6�i`b ��<<7Phone #: �� �'2��
Are ou an employer? Check t appropriate box: Type of project(required):
l.�am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or p hme).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.���odeling
ship and have no employees �ese sub-contractors have g, emolition
working for me in any capaciTy. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance ( comp. insurance.$
required.) � 5. � We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
mysel£ [No workers' comp. right of exemprion per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
, comp. insurance required.] '
*Any applicant that checks box#1 must also fill out the secbon below showing their workers'compensation policy infomiation. -
�\ t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicafing such.
� ;Contractors that check this box must attached an additional sheet showing the name of the sub-conhactois and state whether or not those entities have
employees. Tf the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insuraece for my emp[oyees. Below is the policy and job site
information. � �
Insurance Company Name:
Policy#or Self-ins. Lic.#: [� /n � �5 O+�' a Expiration Date:\ l � �
� ,� . ,. ,n
Job Site Address:_����5�'�'� �� ° `-' City/State/Zip: �i��6t� (�-�/
Attach a copy of the workers' compensation policy declaration page(showing the poticy nurober and expiration date). �
Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the imposition of cruninal penalfies of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invesrigarions of the DTA for insurance coverage verificarion.
I do hereby j'y un r th , 'ns and pena[ties afperjury that the infnrmation provrded above is true anQ conect
;
i � ' qf
Si ature: �_ Date:
� � ._ - 2 2 . .
, � �
Phone#: � :
Official use on[y. Do not write in this area, to be completed by ciry or town o�ciaL
City or Town• Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#•
e��. � c�---� � �
� � �-��,��-- s�,�r
._
� ���-- ��.�
�.� . . . - . j:
� .
, ��
;� -�� � �-�-�
. .
�
. � ..�
.. �
,� . �� � ��� � �
, , r--
tfa x� '^�6x��s'�S r�r�l
_ � W f���U�.J �QE U/s
a ���
� � �
_ _ - - - �
�� 4��d��s;
� ,. ,
f _ ,,
� �.� ,
� � - . .. -. . � . . 41r - �—�_--- L
,�6° �� �! . �' � lb`` �o�,� �; „ ��7,, ��, .
� "'`,~_----__ _ �� w
' , �L `► , '� 'I
_ • . �-IsT 1'� (7 � � T 16 NGr'4�� ,/��GK � .3
�J��� ����'���� �
�
. _ �+ �
� _ m.,.�_ ,. �
�I €�J��O�`-� :�S ��eR �ST�� S'� S'-�L� r�
�
. �
. -ti _.
, j
!
!
� �
__ �
' " ��5��►� ��o� t �. � �.
�
,
��'J(�Eanl F�e��z�..
� ,��� f,o�tlinn
� � �� �y<< ;
�: � U D iL , I �
�` �e�J� �cK - _ — - � ,— - ��'��A�� �K
''' � „ � � ;;�` ` - - --- _ --- _
� �„ -- - . � ' _ _ _ --- - - - - -- - - �
��(L�
- �xi�fF�� LA��. . ` ; , I �, r
�
� � � - ��l� � << � ,� i �����f� 5+�,� ,
. ` ' �2s �crnur�t� � _� . ' �
�:
�r -- � � rf I
. G�J��---a�1 -i�co�.� . , �� ��h�.l'�. i� r� t_���� �/8 = �--
� . , �
, , �
._ _. . . -._._ ...'.�ii�. . '-�_. _.