4 GENEVA ST - BUILDING INSPECTION PUBLIC PROPERTY
DEPARTMENT T
I:I�MFaltslf DIUSCOLL
MAYOR 120 WASMNt=W b''[AEEr♦"Uk.K.rASUCHLSL1-rs 01970
Ta--97&745-959S 6 F=97&740-9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION -
Location Name: Building:
--- - Property-Address
LA
Property Is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: Uh
Address:
Cj a-cr e
Telephone: _ c\ Dcj
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition I Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
-- Mail PermitA--
What is the current use of the Building? V\3n
Material of Building? In 3%r I vw If dwelling, how many units?
Will the Building Conform to Law? "!A Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration# \-a- 1,a�Sa3
Estimated Cost of Project Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
- - - -- -
--- ----- -- Estimated Cost-X$11/$1000 Commerci
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
Date
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The Commonwealth ofAlassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02III
_ www.mass-ov/dia
Workers' Compensation Insurance Affidal,it: Builders/Contractors/Electricians;Plumbers
Applicant Information Please Print Legibly
Name Business/oresization Individual):
Address: 2JA- o ( X
CityrState.Zip: nk c9 oaf, Phone U1 L-12
.are you an employer' Check the appropriate box: Type of project (required):
I. I am a emplover with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
'_.❑ I a.T. a sole pmpic'w^r or partner- listed rn the 2ttached Sheet
'. ] 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 repays or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11-El Plumbing repairs or additions
myself. [No workers' comp. c. 152. §I(4), and we have no 12.❑ Roof repairs
insurance required.] ' employees. [No workers' 1-.El 1-.El Other
comp. insurance required.]
'Ana applicant that checks box y1 must also fill out the section below showing their workers'compensation policy information:
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such
-Contractors that check this Lox must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for ray employees. Below is the polio-and job site
information. (�
Insurance Company lvame:�
Policy=or Self-ins. Lic. Expiration Date: U"/
Job Site Address: City/State/Zip:
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 da% against the violator. Be advised that a copy of this statement may be fonvarded to the Office of
Invesrigarions of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Signature: ,Y A A Date 2—v2
Pbone=: lS— . l-CA— �_�__7 (-,;,(:
Official use only. Do not write in this area, to be completed by ch),or town official.
City or Town: PermitMcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. her
Contact Person: Phone#:
h 4
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