12 GRANITE ST - BUILDING INSPECTION (3) 1 OF 2
2- 1392
The Commonwealth of Massachusetts
1i '�� Board of Building Regulations and Standards CITY OF
') MassachusettS Slate Building Cude, 73B C'bIR tiALGAI
'L•,•• Re riled.I lur'll l l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
(ha-or Tnvr-Furnilr Du clline
This Section For 013 ciul Use Only Building PcrmitNumber: Date Applied: U—l9 -13
N
Building 011icial(Print Muriel Si Dulc
SECTION I:SITE INFORMATION
1.1 Propejty Address: 1.2 Assessors Nlap& Parcel Numbers
/2 Co 2f1�'�,-7 S-f SOGe-^4
I.I a Is this an accepted street?yes no - MnP Number Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area Isq 11) Frontage(II)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.C.qa,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Lone: _ Outride Flood'Lune? Municipal O On site disposal s stun ❑
Check il' ns❑ P po' )� '
SECTION3. PROPERTY OWNERSHIP'
2.1 Ownert of Record:
��7 t✓� ��1 SAS44tq M A-
Nine(Print) City.State,ZIP
I2 beft * S"7— ZNl 3yy
No.and Street telephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Nurttberof Units Other Spccify:
Bnet'Description of Proposed Work':
SECTION h ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
I Labor and.Materials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier
1. Plumbing S '. Other Fees: S
a. \Icchanieal nil\'.\('1 S List:
tiu+inssionl S Total .\II Fees: s
Check No. Cheek Anioum: Cosh \mount:
n. Tnlal Project Cost: s o290 p2, 1/0 ❑p;iiJ in Full ❑Outstanding —BaLmce Due:
M t ra Come,-rr,C -02
SECTIONS: CONSI'MICTIONSERVICES
5.1 Construction Supervisor License(C St.) 16
o l'R-L'S 1 1 Iold4�wp," 7-
wvasc Numhcr Fgtir,uioa Dale
un wc-- ----c-r-
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-;� Q 66f� A-U, 6� I ist CSI. I'%pe Isce 110Okn
)-,7-d-�-Ircct )PC 7-1)"lliplion
019 -76
ti I inrestriemJ
ji�Ti7v—it)35,000 at. 11.)
R
I(C Itooling'Co%cring
%A S I Window and Siding
SF Solid Fuel Burning Appliances
Hiffy Px/ Ceih e or, 44'- 1 Insulation
=D
I c1cphoric Finaitaddr�cm 0
5.2 Registered Home Improvement Contractor(HIC) 111617
MA5�11` bILT6044-U&I r A0 I IIC Registration Nuirilwir
F]IC ctp or I[It'Re ant Name
Ci
No. Einuil address
CityfTown,State,ZIP releatione
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 Istuance of the building permit.
Signed Affidavit Attached? Yes .........AS No...........Cl
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 M uolww tlftm
1-Z
to act on my behalf,in all matters relative to work authorized by this building permit application.
/404610-1 ftlfF� J
Print Owner's Nanic(Electronic Srgnaturc) / QAte
SECTION 7b:OWNER'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 is lru nci accurate to the best of my knowledge and understanding.
fl
Mute
NOTES:
1. :\n ONkner 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!Ui 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
\%N\I% W.1-11 % ;-,.a Information on the Construction Supervisor License can be found at„>%tk 11,1,; �.,% 'III,
2. When substantial%%ork is planned,provide the information below:
Total floor area o*4. ft.) i including garage. finished bascincriL attics,decks or porch i
Gross living area i iq. it,I Habitable room count
\umber of lirQI1I,1V0 Number ol'bedrooms
Number ol'bathrooms \tunbcr
I)pe at healing SN Stein Ntimhcr o(decks, porches
I" pe al cooling it stctil Finclo,Qd Open
I 'I oi,ii Project Square Footage-maN he substituted 11or-I'oml Project Cost"
l The Commonwealth of Massachusetts
Department of Industrial Accidents
_ Office of Investigations
600 Washington Street
Boston, MA 02111
www,mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information y� p Tf ' 0 Please Print Legibly
Nanle(Business/Organi anon/Individual): M l 0 t s�•t y}rG� l�1 r40 /U
1 >�v
Address-._ -> G�l�/� (SUP✓
City/State/Zip:_ > ] Phone#: 179 '
Are you an employer?Check(the appropriate box: Type of project(required):
1.0 1 am a employer with----d 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).+ have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t Remodeling
ship and have no employees - "These sub-contractors have g. ❑Demolition
workingfor me in an capacity. workers'comp. insurance,
Y P Y• 9. ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME]Electrical repairs or additions
3.❑ f am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repalZ
insurance required.]`+ employees. [No workers' 13. 0ffier (r 4S ULJI�iI ��
comp-insurance required.]
°Any applicant that checks box 91 must also fill out the section below showing their worken'compensation policy information.
r Homeowners who submit this affidavit indicating they arc doing all work and then hire outsideeontraetoss most submit anew affidavit indicating such.
;Comn,ctors thus check this box must attached en additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an em lover that is providing workers'compensation insurance or employees. Below is the alit and job site I
P P 8 P I mJ' P policy J i
information. �--�
Insurance Company Name:
Policy p or Self-ins.Lie.#: t,/ `J (51 7 —3 Expiration Da j
Job Site Addiess. //MI1
_�Z . ,17G 51— 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$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$250.00 it day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D1A for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: �q��/ Date'
Phone It I p l z i I
Official use only. Do not write in this area,to be completed by city or town orfeial.
City or'fown: Permit/License#
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#: