20 GOODELL ST - BUILDING INSPECTION (2) C� The Commonwealth of Massachusetts R E C E I V F E OF
a Board of Building Regulations and Standar&iSPEC I IOHAL S' RVIOMY
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate d4b0allS a A 11: S 4
One-or Two-Family Dwelling
This Section For Official Use my
Building Permit Number: Date Appl� d:
Building Official(Print Name) Signature bate
SECTION 1: SITE INFORMATION
I 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
a0 oode�� �+reck Sa)erl' /'1A'
V 1 1.1 a Is this an accepted street?yes no Map Number Parcel Number
1 1.3 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
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?Check if yesK
Municipal 19 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
2 Ee,6agO Srden AlA 019 :�o
Na (Print) UCity,State,ZIP
a Goodell S]-6—C,e4 603 3 J
No. and Street Telephone U Email A ress
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) 19 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Descripton of Proposed Work': �ef>701/e Q S So.. 0
( W nAQULr kD o b I owP� fl'
a S 1G ti �o`e\ ac P o {
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials) Official Use Only
1. Building $ 900, 00 1. Building Permit Fee: $ Indicate how fee is determined: .t
2.Electrical $ ❑.Standard City/Town Application Fee -
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: _h�,J`''
5. Mechanical (Fire
Suppression) Total All Fees: $
6. Total Project Cost:
�00 00 Check No. Check Amount: Cash Amount: _, J
$ , ❑Paid in Full 0 Outstanding Balance Due:',, , �„* f
SECTION 5: CONSTRUC NS RVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name -
No. and Street Email address -
City/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 .......... ❑ 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.
1 Print Owner's Name(Electronic Signature) Date
t 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
Jcontained in this application is true and accurate to the best of my knowledge and understanding.
an `�ec� eG 1 I
Print wner's or Au11 zed Agent's N e(Electronic S ature) Date
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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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 halfibaths
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"
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CITY OF S.U.EM, N.LkSSACHUSETTS
BUILDIING DEPARTJIEINT
• t p• 120 WASHINGTON STREET, 31p FLOOR
*a TEL (978) 745-9595
FAX(978) 740-9846
K1,\tBERi F.Y DRISCOLL
MAYOR THortAs ST.PrERRs
DIRECTOR OF PUBLIC PROPERTY/BUII.DL!iG CO\MSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Leeiblv
Name(Busim-ss/nOrganizatioMndividual):
Address: Z 6001 Jul S 7
City/State/Zip: Sk i /Vt I A 0/1 Phone #: 6003`S U—JJ _3$
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with 4. 0 I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.t ?• O Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp. insurance. 9. 0 Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
rt required.] officers have exercised their 10.0 Electrical repairs or additions
3.161 I am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself.[No workers'comp. c. 152, §10),and we have no 12.❑ Roof repairs
insurance required.)t employees. [iQo workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box ill most also fill out the section below showing their workna'compensation policy information.
t Ih,mcown rs who submit this affidavit indicating they arc doing all work and then hire onside commerors must submit a new affidavit indicating such.
�Contraetms that check this box must aaached an additional sheet showing the name of the sub-eommetora and their workers comp.policy information.
I um an employer that Is providing workers'compensation lusttrance jar my employees. Below Is the policy and jab site
information.
Insurance Company Name:
Policy 4 or Self-ins. Lic.#: Expiration Date:
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 S 1,500.00 and/or one-year imprisonmen4 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
I nvestignions of the DIA for insurance coverage verification.
I do hereby certify under rh1 alms
saannddd penalties of perjury that the hrformation provided above is true and correct,
Date,
Phone#:
Of use anly. Do not write in this area,to be completed by city or town offrelaL _
H
l M-.
City or"town: _^ Permit/License#
Issuing,%uthority(circle one):
1. Board of health 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector ;
6.Other
Contact Person: _ Phone#:
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CITY OF S.U.FNl, NWSACHUSETTS
BLILDIING DEPARTMENT
N• 130 WASHINGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KLNfBERLEY DRISCOLL
MAYOR T Hmw ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BU MDING CONMSSIONER
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:
(name of hauler)
The debris will be disposed of in
fa
/Vo C t l� COL 641 1 P
(name of facility) 77
SWowOsco# (�okJ , 5 er'►/ � �� T�
(ad ress of facility)
signature of perry;& applicant
—T date
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