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53 GALLOWS HILL RD - BUILDING INSPECTION (3) 00 (o The Commonwealth of Massachusetts OF Board of Building Regulations and Standards CITY M Mar Massachusetts State Building Code,780 CMR SA Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only, Building Permit Number: Da Applied: - , © ..1 1 A. cue Building Official(Print Name) ,Signature " Date _. SECTION 1:SITE INFORMATION Z 14�� 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers o 573 1.1a Is this an accepted street?yes V no Map Number Parcel Number p Lam/ 1.3 Zoning Information: 1A Property Dimensions: to ` Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) ��r r� N 1.5 Building Setbacks(ft) �p < Front Yard Side Yards Rear Yard O n Required Provided Required Provided Required Provi ed 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) // City,State,ZIP [ W No and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ 1 Repairs(s) ❑ I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other Specify: Brief Description of Proposed Work : (?eP,ccUA SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: I I I Official Use Only (Labor and Materials 1. Building $ _ U 6ex) 1. Building Permit Fee:$- Indicate how fee is determined: 2.Electrical $ ❑Standard Ciq,Town Application Fee y C'E'O • ❑Total Project CosP(Item 6)x multiplier x 3.Plumbing $ oo! COO-Utz 2. Other Fees: $ 4.Mechanical (HVAC) $ List: - 5.Mechanical (Fire Su $ Total All Fees:$ ression Check No. Check Amount: Cash Amount 6.Total Project Cost: $ 3 )16W, ht ❑Paid in Full' ❑Outstanding Balance Due: TO N •o • "1 � 20 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 2� 12 License Number ( Expiration Date Name of CSL Holder �l List CSL Type(see below) No.and Street Type Description Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&.2 Faintly Dwelling - CiWro,kn,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Tele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) rZ19 !3/ 2— !aZk l --Tc%✓Vl �ire'� 4 o`er HIC Registration Number Expiration Date HICCom�y se or t c � & "�n`�^ �k,y S c r— �,� No.and Street Email aWdress TC�Ss—(,/ &PC &; "3 Ci /Town,State,ZIP 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 ..........I --' No...........❑ SECTION 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW 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' M d actor the best ofmy�lknowledge and understanding. Print Owner's or Authorized Agents Name(Electromc S ature) v' ` D te/ NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who bites 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 can be found at www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns 2. When substantial work is planned,provide the information below: Total floor 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 haWbaths 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.LLEtit, A. NSSACHUSEM BuamiNG DEPAMIEINT 120 WASHINGTON STREET,3m FLOOR tiara TEL ro-Y 745=9595 FAX(978)740-9846 KI\IBERLEY DRISCOLL MAYOR Tttoaus ST.P>ERRs DIRECTOR OF PV13LIC PROPERTY/BUILDING CONMUSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information II_�tt Please Print Leffibly �' wK1lG Name lBusin+ssiOrganization/lndividuap: L Address: ,5.5 2c� L City/State/zip: ,r id 149)47�01&5 Phone#: S 24& Are you an employer?Check the approPrtate bona Type or project(required): 1.❑ 1 am a • loyer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction e— oyees(Rd1 and/or part-time).* have hired the sub-cotractors 2.&1 am a sole proprietor or partner- listed on the attached sheet.: 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. I 9, ❑Building addition [No wodters'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance requited.]t employees.[.No workers' comp. insurance required.] l3.❑Other •Any applicant that checks best 91 most also till out the section below showing their wtxkmat compensation policy infotmohm. 9 I lomeowten who submit this affidavit indicating they am doing all work and thm hire outside cont , m must submit a raw affidavit indicating suds. :Contrrmn that cheek this tan most attached an additional shun showing the came of ne aeb=cammctwa and nccir workr..'comp.policy intotmation. t are an employer that Is providing worker'compensation insurance for my employees: Below Is the policy and jab site information. Insurance Company dame: Policy#or Self-ins.Lie.#: Expiration Date, Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and esplration 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 S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby c u/n/der he pair/u7Q,/,7d pens of perjn that the information provided above is true nd correct Sit: attire; Date- / Phone Official use only. Do not write in this area,to he completed by city or town official City or Town: PermitfUceme Issuing Authority(circle one): 1.Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical inspector S. Plumbing Inspector 6.Other _ Contact Person: Phone#: CITY OF S�UY"Nia IASSACHUSETTS • BU DLNGDEPARTNIENT 130 CiiASHING'TON STREET,3e FLOOR FAX(978) 740.98" KLNfBFRt EY DRISCOLL MAYOR TtIo[.rAs ST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUUMING COMMSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Codc, 7000 CNIR section t 11.5 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 property licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: Z /' C la ys (name of hauler) The debris will be disposed of in a � (name of facility) Ate` (address of facility) signature of permit applicant fe Jchriv17.Jr