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49 HATHORNE ST - BUILDING INSPECTION The Commonwealth of Massachusetts ° Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR RE wE®AL d+2BY 39§9TIO Building Permit Application To Construct,Repair,Renovate Or I a One-or Two-Family Dwelling 3 This Section For Official Use O Building Permit Number: Date Applie . Building Oficial(Print Name) Signature � � e / SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 49 I ka sy�brne Sk _ 1.la Is this an accepted street?yes_ no Map Number Parcel Number 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 Rem 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 yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 44 f g, l,ofr%R - A- kr l H,�b�f (bra, n 01gS Name(Print) City,State,ZIP 7G E4c;4 TArftA- Q7g- 1SS--1.\Q49 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition El Demolition ❑ Accessory Bldg.❑ Number ofUnits Other Specify: Brief Description of Proposed Work': knoyt 9'ok KelAclo v SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire $ Su ression Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 4Soo,� 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �+ CS oU 9S 7 as/1` .,611.E Cc r'f j JC lyPl�pte,\ Cc,rr\�ora License umber Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street: ; Type Description s^gl.P,� yv�yr" �. �� U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 FamilyDwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding p (� SF Solid Fuel Burning Appliances R7p—] OG' q1 I Insulation Tele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Exp HIC C ration Date ompany 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..........6❑ 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. 3.-,YN caw.�re A Ind Owner's Name(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. Print Owner's or Authorized Agent's Name(Electronic Signature) 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 Ntiww.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.rov/dps 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 half/baths 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" o, CITY OF S U.EN,1, ANSSACHL'SETTS .rY BUILDING DEPARTMENT 3 i! '�r 120 WASHNGTON STREET, 3'o FLOOR • 'CSsnb - TPL (978) 745-9595 FAx(978) 740-9846 Kl\IBERLEY DRISCOLL TH ;V{,'1YOR OMAs Sr.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUILDNG CO\L iISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anpficant Information Please Print Leeibly V:II71C (nusinussOrganizatioro'Individuaq: ,Ghv\ CQwssrq- . TL Ge,\ert,\ Cahk/4Cd . � Address: el fr4w(-frlCaz S City/State/Zip: Akf-^\ Mci. 'Z197G Phone N: q 29- -S9-a' 9I74' Arc y an employer?Check the appropriate box: Type of project(required): I.WI am a employer with V 4, ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 ran a sole proprietor or partner- listed on the attached sheet.: . 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers'comp. insurance, y, [3 Building addition INo workeri comp. insurance 5. ❑ We are a corporation and its officers have exercised their ME] Electrical repairs or additions required.] 3.❑ 1 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 repairs insurance required.] t employees. [No workers' 13.❑ Other comp.insurance required,] •Any applicant llur chucks box 91 must alsu fill out the mdiun b:lowahowing their workers'eumpensmiun policy information. 'I bun¢owm"who submit this affidavit indicating they arc doing all work and then hire outside contractors moss suhmil a new a?:davit indicating such. ;(lmtmctnrs thus check this box most mtached an addidurwl shoes showing The nano of the subwumraators and their worlicrs'comp.policy infumtation. l nor un employer shut is providing workers'corrtpensailon insurance for my ertrployees. Below is the pollry and fob site iufunuatiom ^� insurance Company .Name: (} ^���Se 5.---_[/&— /4S^ Gq 6� Policy A or Sclf-ins. / c. L,,ic d:. Expiration Date: Job Site Address: "t / M,; . +knrl.e Cily/State/Zip: 99]Pn-, r'19, Q I cr7© 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 arNIGL c. 152 can lead to the imposition of criminal penalties of line 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 line of up to S230.00 a day against the violator. Be advised that a copy of this statement may bc:forwarded to the Office of Invasligmions al'the DIA for insurance coverage verification. _ f do hereby certify under the pairs and penatles of perjury that the hr/oratativrr provided above is true uud correct. (t-�� �1 a .Sienuurc' �� Data: � _ A a�� 01 Official use only. Do not write in this area,to be completed by city or town nfficiaC City or Town: _.__. . .__ Pcrmit/t.lccnse fl____ Issuing Aulhur4y(circle one): 1. (bard of Health 2. Building Department 3.Citylruwu Clerk 4. Electrical Inspector 5. Plum71nspccto]r 6.Other ... -_-- Contact Person: _ t y 'CITY OF JiUEIN f, LY Li1SSACH US E 1 i s t OUILOM;DEP.IRTMEYT 130 WASHLNGTON STREET, 3w FLOOR ' TEL (978) 745-9595 KIMBERLEY DR-ISCOLL FVC(978) 740-984S tbUYO t Trgo.%LAssT.PIERR3 DIRECTOR OF PUBLIC PROPERTY/BCLLDLN<;COJDIISSIO.VER Construction Debris Disposal AftIdavit (required for all demolition and renovation work) rn accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of NIOL c 40, S 54; Building Permit k 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 NIGL c 111, S 150A. The debris will be transported by: (namc at hauler) The debris will be disposed of in --_—_-- (aarneattacJity) — -_----(aJJr'ess or laeility) signotureofpermit.rpplicant —