1B GREENWAY RD - BUILDING INSPECTION R CEIVED
RV�CES
s The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards �p p WIN[
�
u Massachusetts State Building Code, 730 CNIR 101 I�N•14 ' , 33
:tf
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only .
Building Permit Number: Date Applied:
Building 01'ticial(Print Name).
Signature - Dale
SECTION 1:SITE INFORMATION'
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I.I a Is this an accepted s ree0 yes o0
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Lot Area(s It Frontage(It)
Zuning District Proposed Use q )
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
t 7 Flood Zone Information: 1.8 Sewage Disposal System:
1.6 Water Supply:(M.C.L c.d0,§Sq)
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2: PROPERTY OWNERSHIP':
2.1 Owner of Record: 5 0-7' pY�jC/ D1�70
�,tl G2E
throe(Print' City,State,ZIP
�rr3 Cs�.ywrf y R-� 802..2,33� �SS^
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all thatply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s1 El apItemtion(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other Specify:a2PSOFiN�,
Grief Description of Proposed\VorV:
L A C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlcial Use Only
ItemLabor and Materials)
I. Building $ 1. Building Permit Fee:3 Indicate how tee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S 2. Other Fees:
.5
I.Mechanical (IIVAC) S List:
i. .\Icch;micol (Fire S Tutai All Fees:S
Su ression)
�p Check No._Check Amount: Cash:lnutnnt:_
6.Total Project Cost: .S ❑Paid in Full ❑Outstanding, Balance Due:
R�ai t_ 0 2 z M Aeg S-r- rn A(LIED 44 (7,5
U
SECTIONS: CONSTRUCTIONSERMES
5.1 Construction Superyisur License(CSL) 02
. .3, c• a 1;0. rl•1
License Number E. iruliu Datu
None of CSL Older
Lill CSL'fype(see below) (J
Z Z e IdFC�STD ^ Titte Description
No. m,d Street /
U Unrestricted(Buildings Lip to 35,000 cu. 11.)
f7 79 DpG/ L�/J/� �1F60 Restricted 1&2 Family Dwelling
C'ilylfuwn,State,Z P �— �I Masonry
RC Rooting Covering
INS Window and Siding
SF Solid Fuel Burning r\ppliances
v�8f �p�Of'b I Insulation
1'elc hone C•nmil address U Demolition
5.2 Registered flame Improvement Contractor(HIC) �YyCp�/ �? �7 �S-
40 HIC Registration Number Expiration Date
I I C Co np;my Name or HIC Registrant Name
2 6�-fif 4Z 2E
No. a,d � o14 079 � -0/0( Emu t address
Cit /Town,St.to ZIP / P4`Teele hone
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 Isivance f 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's N:m,e(Electronic Signature) Date
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 true and accurate to the best of my knowledge and understanding.
, n R, d0yu€ V- c/ 22 20/�
Print Owner's ur Authorized Agent's Name(L'Ieelrunie Signature) Dane
NOTES:
I. An Owner who obtains a building permit to do hie/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 thud under NI.G.L,c. 1 d2A.Other important information on the HIC Program can be found at
www.muss..,•ov'uca Information on the Construction Supervisor License can be found at wvvw.mass,eov.! Ls
2. When substantial work is planned,provide the information below:
Total floor area(sq. 11.) (including garage, finished basementlattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type o fheating system Number of decks/porches
1'ype of cooling system Encluscd Open
4. "I'ulal I'rujact Syuarc Fuuutge"may Ic substituted fur"total Project Cost"
CITY OF Szq.E,%I, ANSSACHU'SETTS
' r BUILDINGDEP MLEINT
• ) �' l_0 WASHNGTON STREET, 3
� w FLOOR
T EL (978) 745-9595
Rio(978) 740-9846
KIMBERLEY DRISCOLL
N AYOR THohLNsST.PiF_vm
DIRECTOR OF PUBLIC PROPERTY/BUUZNG CO\CAISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 'l Please PrriinnttLegibly
Name(nusinuss Orsaniration,'I mlividual)ezg_e bY/7��-
Address: PZ �A y T 7- p i
City/State/Zip/�ziJf.✓jOy! ^ir9 �t9ly0 Phone It:L ,A er 01
Arc yo employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with e-1 4• ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ film a sole proprietor or partner- listed on the attachcd sheet,t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. y. ❑ Building addition
[No workeri comp. insurance 5. ❑ We are a corporation mid its
required.] officers have exercised their
f0.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL l l.❑ Plum repairs or additions
myself. [No workers'sump. C. 152, §1(4),and we have no 12, oof repairs
insurance required.) t employees. (No workers' 13 ❑ Other
cutup.insurance required.)
•Any applicant nut chucks boa AI mutt also fill nut the xel:en below showing their workeri eompemnion policy inlbrrnatiun.
'I bnncowm"who submit this a8ldnvit indicating they am doing all work and then hire outside contractors most sohmil a new aft davit indicating such
;Gntrutunr that check this box mtut attached on additional shout showing au name of the subea'aract'r,and their workers'comp.policy information.
1 am an employer that is providing workers'c•ompettsatloo insurance for my employees. Below is the policy and fob site
informuliam
Insurance Company Name: p—
Policy 4 or Self-ills. Lis Mye �4s r/1p 77, 36-6"lqf Expiration Date:
/Zy�
lub Sile Address: _/ A City/State/Zip: �e
,Vlach a copy of the workers'compensrtloa pulley 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
tine up to S1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to$230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invesligations ol'the DIA For insurance coverage verification.
I da hereby e• rfy a er the pahrs alld tenafties of perjury that the htfonnadon provided above ix true and correct.
Son. t e' + 7 � Dater �zdl7�
Phone i: /'
OfjPeiol use only. Do not write in this area,to be complied by city or rown agiriaL
City nr Town:
Issuing Aulhurity(circle one):
I. Board of Ilealth 2.Building Department 1.C•ity(fuwn C'Ierk 4. Electrical Inspect7PIumbinghuipejctor
6.Other
Contact Person: Phone tt:_,---___--_--.�
[
CITY OF S:UL&NI, tiLXSSACHUSBTTS
l ' OU LONG DEPARTM&NT
120 WASIANGTON STREET, 3'4 FLOOR
T EL (973) 745-9595
F.ux(978) 7.10-9844
tUJtBEI2LcY D(LISCOLL
&LAYOR T HO.%LU ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CONWISSIONER
Construction Debris ,Disposal Affidavit
(required for all demolition and ronovation work)
In accordance with the sixth edition of the State Building Code, 730 CDAR section 111.5
Debris, mid the provisions of tbIGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be t 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by rNIGL c
The debris will be transported by:
y
(name ofhauler)
The debris will be disposed of in
(narne of facility) -
(address of rtcitity)
sign re or permit applicant
latc