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21 GARDNER ST - BUILDING INSPECTION 1 --- I'hc Cbntnwmvuslilt of�1:usachusctU _ _ f BuarJ of Building Regulations duld Standards CI'I.1' OF lr klassachllsclls Stale Building Cude, 7SB CNJ S,\LFXf ?� Building Permit Application To Construct, Repair. Ren ate Or D- nolish Iteriu / Ilur:u// '\ (her-ur 7-irn-Pinndt' Our/liu,�r f This Section For Ot'ficial L. Onl Building Permit Number: __ Date Applic Iluilding 0111cial(Print Mune) Si to Date SECTION I: SITE INF IATION L I Pro eras AJJres : L1 Assewrs blip S Parcel Number I.la Is this an acre led street? 'es no Map Nunthcr I'urcel Nwnher 1.3 Zoning Informatlont 1.4 Property Dimensions: tuning D— iflr�- Proposed(l—W Lut Aron(sy III Frontage I.! Building Setbacks(it) (11) Front Yard Side Yams Required I'rovidud Rryuircd Provided Nryuircd Huor YwdI'roviJeJ 1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flaod Zone lishrmation: 1.8 Sewage Disposal System- IN bit ❑ Private O Zone: _ Outside Flood Zone? Cheek if es0 Municipal O Gn gild dispose,sl.ftem (3 SECTION dt I: PROPERTY OWNERSHIP' t,l Ownert of Reeor 3 v N,une(Pnnl) Cu) 7<)atu,llP Nu.and Street i I - - - C = relephone Emuil Address SECTION d: DESCRIPTION OF PROPOSED WORK'(check al that apply) New Construction Cl Existing Building p Owner-Occupied O Repairsls) Alteratfon(s) O Addition ❑ Demolition O Accessory Bldg.❑ Numberof Units Bri f Description of Proposc Work": Other ❑ .Spccily: SECTION 4: ESTIJIATEO CONSTRUCTION COSTS Iluill Estimated Costs: ILabor and.\ltterials) Olilclal Use Only 1. Duildillg S i I. BuilJins Permit Fee: f Indicate how fee is determined: '. I'leclrical S 0 Standard Citffussn Application Fee 11'lunihing S (3 Tutal Project Coll I(tent 6)1 mulliplier '. Olher Fees: S - J. \Icdt.ulicul ill, Liss: 1lcehanicdl ifnu _ _---w-`-u- � `u reaiuna S rota, .UI Fccf: S_ -- —•— -- ._ . ._ ._ n I'ntul Prrlject Cult: i �� l'hvdk \'u. _. . ( 11"k lntouut. . _. .._.. — C.i�h \mount: O P.iiJ in full 0111standins B.tLutce Due: tit.('I'ION t: ('ON%I'RIIC ION SEKVICFI; 5.1 C'unslruCliunsullenisurucettseI(St.) I iCcu>¢ Nwnhcr I yvraioll Ikuc GBH - --- V.uneul'L'� 16,IJcr I1.1 CSL I\pe bee helu,sl._—.--•- _—.._ Descripliun ,V,�nJ>Ircet II IlnnstricteJ IIIuIWill a ti to)4,UIIQ al. lt.) y1 �'�Lj� SI \laslnl l'ipi I'al,n,Slale,LII' KC I(mlin Cus¢rin N'S N'illdow.utd 5idin SF SulidfuelIhuning,liPOWICcs i I Illsululiun gel ,,g D Dena)liliun ale bona I Mail AdN.Si 1,2 Rrgistcred Ilume Improvement Cuntrncfor(HIC) / © U - ) IIIC'I(egblrati lz Number IiipirWion�ale bcbo I IC 'um n) Nanw or I I 'I egislr l sum limail aJJrvsa No IJ S ^t D fcl C own, tat ZIP 13C(6)) SECTION 6:WORKERS'COMPENSATION INSURANCE eed and submitted with the application.Failure to provide Workers Compensation Insurance affidavit must be co pi this affidavit will result in the denial of the I"I isuanceelt the building permit. Signed Affidavit Attached? Yes No...........0 SECTION 78l OWNER AUTHORIZATION TO BE COI►IPLETED 1VHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property,hereby authorize to act an my behalf,in all matters relative to work authorized by this building permit opplicatlon. Data I'rinl Uwncr's Nwne lElcetwsk Signulnro) SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION By ente ing Iny name below,I hereby attest under the pains and penalties of perjury that all of the information contai in this ieatlan is true and accurate to the best of my knowledge and understanding. J� f)ulu uu t ,+ncr' ur: ❑horvQd Al;en1's Mtoiv I Jcctr'Me Signauual NOTES: tnulUmisterediobtainshe ehnpraPmuntlCummctorIHIC) Program ).vllo do his her oIwn Ivurk.0rrurer shavea\eatoliheubirregistereetiunconurnctur ion on the pr`1g`am or guuran Iyi l fodlunder ation un the.I:. 141-A. Other important uc:ian Supers oar Li erase cin be found atC Pruyr�l.��ntballfaunJ at \hen substantial Iwrk is phuutCJ,prusida the inlolltludinglgarege,tinisllcd basement itties,decks or poichI --- — folal hour arCa I+y. If l . H:Ibllable rUU111 ialllll _ .. ... . llfoii Its ing area I ict. Il.l ._. .- \11111t1cr of hedrovills - \unlhcral'lireplaas _ - -- \uillhcrufhalth;uhs \wuherol'hathrowus \lunhcrofJceki. par.hci I\pc of healing i),Icm I'nclo eJ ltpen I �'r,llccl SkItore fool-14c Illlll he HIh,111111 Al hV"I',ILII I'rojhl(off. CITY OF &U-E.M. ANss.41CHLSETTS t 3U LLD NG DEPAIMW-NT 120 WASHIINGTON STREET, 31O FLOOR 4 TEL (978) 745-9595 F.t.Y(978) 740-9846 Kl\fBERLF-Y DRISCOLL MAYOR Tiimus ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILONG COSLUISSIONER Workers' Compensation insurance Affidavit: Builders/Contractorv/Electricians/Plumbers Applicant infnrmatinn /t/) Q ny Please Print Legibly Narne(BusinasaOrgani:ati)nilndividual): ///(��•T R "e Address: !: wige City/State/Zip: > I Phone It:ZZE-:9a Are u an employer'!Check file appropriate boa: Cype of protect(required): 1. I am a employer with 4. I am a general contractor and 1 6, New construction employees(full and/or pa -time).' have hind the sub- contractors 2.0 i 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. 9, Building addition [No workers'comp. insurance 5. 0 We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.[No workers'comp. C. 152, §1(4),and we have no 12.0 Roof repairs insurance required.)t employees.LNo workers' )},0 Other comn. insurance nquircd.J •Any applicma dwi duxks box al most also fill Out rho section below showing their worker'compensation puliry inlarmmfon. r I Lvneuwnora who submit this affidavit indicating they am doing all work and thrn biro ouride contractor must Submit a new afndavit indicting such. :Conimlors that check This box must attached an addiliuMal sheet showing the nume of the subcontractor and Their workers'comp.policy infomunnco, l um an employer that tr providing workers'compensarlorf insurance for my employees. Below is des policy and Job site information. ( lnsurance Company Name: M:J yt�i1.y0-4c.yyJ (,, ,y(4? /2/' / 6� Policy 4 urSelf-ills. Lie/d: i' 0 ct('1 y" (p ��— _` Expiration Date:1S/�/r j�i ��✓ Job Site Address: V t/S � / City/State/Zip: ^P`L/� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A of biGL c. 152 can lead to the imposition of criminal penalties of a line up to 51,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to SM.00 a day against the violator. De advised that a copy of this statement may be forwarded to the off lee of investigations of the DiA for insurance coverage verification. l do hereby c errij order the s and peaahies of perjury that the infonuutlon provided above is true-aced correct. .S',. .I ` (— Data• � (� OJJirial use only. Do not write in this area,to be completed by city or town nfJicluL City orTuwn: _ Permit/1.1cense# Issuing.\ulhoriiy(circle one): ---- ---- 1. Board of Ilealth 2.nuilding lleparhnent J.Cilyffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.OWer Confact Person: __ _.. Phone ti: CITY OF S.0 EM, .NL WSACHUSETI'S BLILDL`lG DEPARTMENT N 130 WASHINGTON STREET, 3" FLOOR ` TEL (978) 745-9595 , F.kr(978) 740-9M KIJ(BERLEY DRISCOLL N AYOR THo.sus ST.PIERRE DIRECTOR OF PuBuc PROPERTY/BUILDNG CONWISSIONER 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 I It, S 150A. The debris will be transported by:' (name of hauler) The debris will be disposed of in (name of facility) � (a dr s of facility) signs re of permit applicant date 4cbris�IT,bx