205 FORT AVE - BUILDING INSPECTION :a I
f I The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7''edition R v sr ed aJQJ nub
Building Permit Application To Cons pair,Renovate Or Demolish a 1,2008
One-or Two amily elling
piisT/ction For OQkial Use Only
Building Permit Number: Appli • ' i • C/
Signature:
(pr C
Building CommisslaaerWpMor of s Date
SECTIO .SITE INFORMATION
1.1 Property Address• 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided „ Required Provided
f
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal '❑ On site disposal stem ❑
Public❑ Private❑ Check if yes❑ �O system
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Records /
G11ec-\'.e �etie65 705 Fr7-
Name(Print) Address for Service:
97? sa8
Signature Telephone - --
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ 1 Existing Building PI I Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed
,1 Work : tJ o-u-3 Z a 1&oo r 'zdZ` A- Qa.:`-�^ ` 41, �� 1
�--rr X�S'4ifiQ• F'1h� �v o.-.n • C7r�,�e0 aYWA 6>��i].
AI EAT U
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: L
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 7 2 S0 ❑Paid in Full ❑Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
066r,03
_T ma S � License Number Expiration Date
Name of CSL-Holder List CSL T
(w ype(see below)
Address14.
Type Description
U Unrestricted(up to 35,000 Co.Ft.)
R Restricted 1&2 Family Dwelling
Sign
_ ' - - M Masonry Only
"35-7 RC Residential Roofin Coveri
Telephone �WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance lnstallation
D- Residential Demolition
5.2 Registered Home Improvement Contractor(MC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(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 ........� 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.
Signal=of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, `57 Y� N� (no & ,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. {� `
—!T,V" I leo c�
Print NaarV
Sign e of Owner or Authorized Agent Date
Si ed under the pains and penalties of
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 not 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 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(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 Square Footage"may be substituted for"Total Project Cost"
i CITY OF S.UEM, NIASSACHUSETrS
BUILDING DEPARTSM.`iT
• 120 WASHINGTON STREET,San FLOOR
TEE. (978)745-9595
FAx(978)740-9946
KI1BFRi FY DRISCOu
THOMAS ST.PIERRB
MAYOR _
DIRECTOR OF PUBLIC PROPERTY/BUUMI SSG COMMSSiONER
Workers' Compensation Insurance Affidavit: Bailders/Contractors/Electricians/Plumbers
Applicant Information. .. _ Please Print Ledbly
Name(Susinesaorganiralionilndividtul): T'M 3 J� `�_•C/S
Address: q C ee s-v AV10
City/State/Zip: S a 1,e t-,-, M 14 Phone#: 97Fr - 7 3 S=0 3 S 7
Are you an employer'Cheek the appropriate box: Type of project(resf")-
L V I am a employer with 2 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-conttactots
2.0 I am a sole proprietor or partner- listed on the attached sheet.t 7• El Remodeling
ship and have no employees These sub-contractors have & ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp, insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEJ Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees. [IQo workers' 13.❑Other
comp.insurance required.]
;Any 1PPgam dial ehcdro bone Ul must also fill car the section below showing th a anngt eirwtnit ' m adon Mliey infutm oa ad .
I romccaman who submit this amdwit indicating Uuy ate doing all work and than him outside eomitacons must submit a new affidavit ittdfcai as such
:Cunttacto s that chnct this brat must anachod mi add u mol short showing rue name of ate subsontrMers and their wasters'comp.policy infermndon.
1 am an employer that br providing workers'compensadon insurance for my employees Below Is the policy and Job sift
information.
Insurance Company Name: 1^Icaa^ U r rs
Policy#or Self-ins.Lic.#:.1A)C,2 --".5 1 p2 3 7 7� S 5:=O f r7 Expiration Date.,—y' :�O y/y/2
Job Site Address: O � j-'orT Ave. City/Staw/Zip: So ///lem 4 70
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations crthc DIA for insurance coverage verification.
1 do hereby certify under the pains and penalties of perjury that the hiformadon provided above is true and cornet
Signature, !�/ Date:
Phone#: 5 7? ' 7 3 3- 03 S-7
Wicial use only. Donor write in this area,lobe completed by city or town oJficiad
City or Town: Permit/L)eeme#
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#:
CITY OF S U.ENl, N-LksSACHUSET17S
BLunLIG DEPARTJIEN'T
• IA ONO
120 WASHNGTON STREET,V FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI%>BEItIEY DRISCOLL
MAYORTHomAs ST.Pwj=
DIRECTOR OF PUBLIC PROPERW/BUHMING COMOSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
Nor"S i�e—
(name of hauler)
The debris will be disposed of in :
(name of facility)
�l.�bl wr D 5Co 4 Q. 50.�QWt
(address of facility)
signature of permit applicant
025 - //
date
Jcbn.vff Jm