9 HARBOR VIEW TER - BUILDING INSPECTION (3) I� .� --- I'he C'omnwnwc;thh of Ni:usmchusclts -
floard ul'Building Regulations and Standards CI I'Y OF
�I t NLtssachuscits State Building Cude. 730 C'NIR S,\Lli.\I
lteriedd 16u 'n//
L.,.•
13tidding Permit Application To Construct, Repair. Renovate Or Demolish a
Otte-or Ticu-Furnilr Dn ellin.q
Phis Section Fur Ol'fici - se Onl
Building Permit Number: Date pplicd:
Iluilding Olticial(Print Milne) Signature Dale
SECTION I:SITE INFORMATION
1.1 Property Address:. 1.2 Assessors Slap& Parcel I u ben
I.In Is this an accepted street?yes no \lap Norther Parcel Nuulhcr
1,3 Zoning Information: Li Property Dimensions:
/using District Proposed Uw Lot Aron(sq II) Fronlagc(11)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Ihiblic❑ Private❑ Zone: _ Outside Flood"Lune? Municipal❑ On site disposal s)stem ❑
Check if ns❑
2.1 Owner'of
SECTION1: PROPERTY OWNERSHIP'
Record:�
1r'13zy =/ z7-//- A/ o/97d
N;unc(Print) city.state.zip
Nu.;md Street relephune Finaii Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Specily:
Brief Description tfProposed Work':
t��i�9d!/fz 22t T-� cc lr i r i/' 9�✓� int!(� Ol(J
T.�lc-Gh-
e
SECTION J: ESTIJIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Laburand Vaterials)
I. Building v 1. Building Permit Fee: S Indicate how fee is determined:
'. lilea ❑rical $ Q
Standard City'Tussn Application Fee
' ❑Tutnl Project('asl'(Rent 6).x multiplier
I I I'luwhing $ C—) '. Other Fees: S_
J. 11sli.mical ill\ %C) $ List.— ._---
Cu.+rcisionl $ rotal .\II Fees; $__---_----
Ch"k \o. Check :\nunnn: l .uh \uenmt:
o lblul Project Cost $ /`j 6 C) U t7 Paid in Full O Oulstanding Bal.utce Due:
l
SEC I ION 3: CONS I'RUci-ION SERVI('F.S
rI-1
structiunSupeni%url.icenxe(('Sl.) C SrD/ M
I icen.+e Nwuhar01. IC-- 1
eel
I�nnstridcI I UuJJin lx ii io t5,U11U cu. IL1
✓� �'v/C�.-�L__—V. .__— He.uideJ L'l'1 P.unil Illlcllin
Cilsifoa n,Slate.Lll' .SI ,\lawo
I4C' Itl.—in C'os erin
...—. AS Aindou;.mJ Sidill
SF Solid Fuel Miming:\pplianccs
y�o��VT �lUrt2 I Insulation
I'cle hone 19nuil addrexs r/V D Demolition
5.2 Registered Ilume Improvement Contractor(111C)
III('Itegistration Number I?cpiruliun Dutu
I IIC•Compan) Name or I IIC Relt6tram Namu
No. wid Street Emuil address
City/Town. State ZIP rele hone
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O No
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Uaoer's Nume(Elcorunic.Signature) out's
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
contained in this application is true and accurate to the best of my knowledge and understanding.
I'nm Da ner'x ur:\uthoriieJ,\gent'.+Name 11AVU11nlc.Signahuu I Data
NOTES:
1. .\n Usiner sihu ubiains a building permit to do his.her usan work,or an owner who hires an unregistered cuntractur
I nul registered in the Hume Improvement C•unmictur(HIC) Program).will no have access to the arbitration
program or guaranty fund under\I.G.L. c. 141A. Other important information on the HIC Program can be Iound at
n .r•. , + 1 I Information an the Construction Supervisor License can be found at t+lt,l 111.1,: ,., 1I11,
', \Chen substantial Durk is planned.J.
pruviJe the inlunnatiun below:
ft+tat Ilour arm I sq. IT.1 - _I including gauge, linished basement aria.Jerks or purcln
Grosi lie ing area i sy. 11.1 .--._ ___. _._ , -_ habitable ruunt wont _
\umhcrol'liretlacex .. ._ _ .. _._ Vunthcr Lit'hcdruumx '- -. ... . .. .. .
\umhcr of hathrounix \'umticr of half hathi
I)pc of halting x)stem \umher al'Jecks pl,rdies
I)lie nl'coolingi)acnl I'nela+cJ O11rn
) 'i.a.tl Prolco Squat%: Foot-1 Vie"Ill a\ he tlbHlltacd ITV l otal PrUjell 01,1-
e '}
CITY OF S.tt.lr.,Nf, AUSACHUSETTS
JL'LLOLVG DER1AT unNr
I 20 TAMLVGTON STAEEr, }'O FtOCR
� I11. �97Z� 7�1-9595
K1J®ERI Y OUXCLL FAX(973) 11Q.93w
NWCA MoUU ST.7m"
OIRECTOtt cr PL auc pROpritTY/s(;MnLYG c0J0ilsstON Etl
Con3tructioa Debris 013pos31 Aft7davit
(required for all demolition and renovation work)
rn accordance with the sixth edition of the State Building Code, 730 CUR section 111.1
Ocbris, and the provisions of WCL o 40, 314;
Building Permit N is issued with the condition that the debris resulting from
111, S I JOA.
this work shall be disposed of in a properly licemed waste disposal facility as defined by NICL c
The debris will be transported by:
� —('n.una ul hauler)
The debris will be disposed Orin :
(namfr of hc�luY)
l��dreu arl�cihiy)
4 Nr u(ru i •rnf
C['I'Y OF S,UE•\1, 2%L1SSACH[:SETTS
s BUILDING DEPdRT�IE\r
120 WASHL�IGTON STREET, 1 a FLOO
jtta. TEL 978 745.9595
R, x(973) 1.10.9844
t,j_\ll3 0.[F.Y DRISCOLL
�L�YOA THO\L�s ST.Pt&aRl3
DIRECTOR OF PUBLIC PROPERTY/BI:RDING CO\LMISSIONEA
Workers' Compensation Insurance Atiidavit: Builders/Contructur.i/Electrlc(ans/Plumbers
�pplicnnt Infitrmrtinn Please Print Legibly
V;IIflC(Husirw+r.Urgtnuatian,lndividu.d):,�j���—�wy��t-r—Q� ���
Address:l��
CityiSratc/Zip: r y/// /� QylYQ rune N: �Jcy1 3 6
,ire you in employer?Check the appropriate boat Type of project(required):
1.0 1 an a employer with 4. 0 I an a general contractor and 1 6. 0 Now construction
mployces(rill and/or part-time).* have hired the sub-comnctars
2.alama sole proprietor or partner. listed on the attached eh wL t 7. ❑Remodeling
ship and have no employees These subcontractors have V. ❑ Demolition
working for me in any capacity. warkers'camp. insurance. 9. 0 Building addition
(No wurkcrs.comp,insurance 5. 0 We are a carpnration and its 10.❑ Electrical repairs or additions
required.) officers have exercised their
).0 1 am a homeowner doing all work right of exemption per MGC 11.0 Plumbing repairs or uddillons
myself.(Na workers'comp. c. 152, §1(4),and we have no 12.0 Roor repairs
insurance requiredl t employees.(No workers' 13.®Other M /cE. y/�
sump.insurance rcquired.l
,toy applivan Ow cbovke but rl moat Tics nil uat the%%flue below.howinI their vakrn'compensation pulley innumotlon.
'I hwneowtwn i he whmN Ohio Affidavit indieuine they An daing all work and then hire uunide con(netan must submit t new anfdavil indtofing.uch.
l',mOnrton that chock this box musts Anxhud m addinurwt.hst showing the nwna of the OutFaunlrutan and shalt workere'wmp,pulley inlannatlan.
fain an darployer that pruvldlnX ivorkers'cutnpduratlan lnrurance%r my empluyeer, Below it the policy and juh sirs
rufuanudarr.
Insurance Company
Policy U or Selr•ins. Lie it: Expiration Date:
tub Site Address: Cityislatelzip:
Albeb a copy or the workers' compensation polity declaration page(showing the policy number and esplradon data).
h'Jiluru to secura coverage as required under Section 15A of MGL a. 152 can lead to the imposition ofcriminal penalties of a
ring up to il,500A0 und/ur one-year imprisonment is well as civil penalties in the form of STOP WORK ORDER and a fine
of up to 5150.t10 u day JgaUtSt the viQhMr. Ile advl.fed that a copy of thit.,wicment may be rurwirdcd to the Office or
I,n c•stigauiunt,d the FAA Ibr ioturinctt coverage vcriticafiun.
!du hrrrby ru ' rJdr thw pains surd pdnalrlrr Jirperjury that the fret/unnuNmr pruvidrlabuav 1.t rule sad aorrrrtDate:
Ulficiaf nee Daly.. Da,Tor tvritr in this area, to be completed 5y city up town njjlrial
Gry nr I'awn:. PermiriLlecme i
hsuio-kwhurily (circle one):
1. Iluard sat'Ifeolih 2. Ituildln., Depi,itnent 1. ('ilyi Town Clark n. Etdetrieil toy)ectnr i, Plumbing Inspector
6. 00wr _