6 HAZEL ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
CITY OF
M
Board of Building Regulations and Standards SALEbI
Massachusetts State Building Code, 730 CINIR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
i, This Section For Official Use
Building Permit Number: Date ed j. /
sJh
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORlMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
C {1192t_ (_ S7
1.1a 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 Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (1M,G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2:, PRO PERTYOWNERSHIPV
2.1 Ownert of Record:
C .�vJZCL 7 t> 3t9LCM K14— 01 T 70
Name(Print) City,State,ZIP
6 }iA 2cL -S7• Q3$ 7SOt10o� 4,07eKj D CO1'-( C4SS1- c7
No.and Street - Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building 0 Owner-Occupied ❑ Repairs(s) X I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number ofUnits� Other ❑ Specify:
Brief Description of Proposed Work': ' C1f N G i PO T7 191VD Pe ' 1 /N6 S
l.—')/ 7/a 6r9LU S 7C_ v2 s '7u i3E Wz v-�—y✓CE
0A) 7H ea V 19 cic' rO RCNDS ejo,eK _70 Vie!-: � c
Ti W 5 7 FLO v s
SECTION 4: ESTIMAUD CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only,
Labor and Nlaterials y'
1. Building $ 3� e�(� ? L Building Permit Fee S Indicat;hovlee ow determined:
❑ Standard.Cttyrrown Application Fee
2. Electrical 5 s
❑"total Pro3ect Cost (Item b)x multiplie3. Plumbing 5 2. OtherFees: S
4. N4echanical (IIVAC) 5 List:
5. Mechanical (Fire
Total All Fees: :S_
Check No. Check Amount: unt[.G. d'ntul Prnjuct Cost 5 ,3 S'00, <D� ❑ Paid in Pull C Outstanding Bi --_---_-
f1 C / l e ( 6A'{ru 7v7/
M,t4/41 l.e -j-D I,
SECTION 5: CONSTRUCTION SERVICES
5.1 Con.sh•uction Snpervisur License (CSL) _ 066-7b
P)70/1( �O� C Z Y�� __ License Number Gepiration Uate
Name ofCSL I folder
List CSL Type(see below) ,
.3 E H(S7v2 $0 nJ G /) Type Description
No. and Street
U Unrestricted(Buildings up to 35,000 cu. tt.)
tKl,0 0 LL TO•t) f/ 0 f Restricted 1&2 Faintly Dwellin
City/Town, State, ZIP MI Ivlasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Q�� ? �(c70S (�N7EKJ C�(/7CWS t•,t I Insulation
1'ele hone Email address D Demolition
5.2 Registered Hone Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or IIIC 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 ..........X No ...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
n
I, as Owner of the subject property,hereby authorize /- P-r o/C( J0A) (? `((Q
to act on my behalf, in all matters relative to work authorized by this building permit application.
A"'TONI DoNC) ((c S:
Print Owner's Name(Electronic Signature Date
SECTION-, )WNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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 ofmy knowledge and understanding.
Print Owner's or Authorized Agent's Nance(Electronic Signature) Date
NOTES:
I. :1n Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(riot registered in the Horne Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty t'und under M.G.L. c. 142A. Other important information on the HIC Program can be found at
tvww.ntass.<,ov oca Information on the Construction Supervisor License can be found at uww.inass.•tu�rdL
Fre
n substantial work is planned, provide the information below:
or area(sq. (tJ _(including garage, finished basemendattics, decks or porch)
ing area(sq. tit _ _ Habitable room Count
of tiraplacCs. Number of bedrooms .-_------_--
thallir")Yy
oms Number of halt baths ---- _
— --eating stewooIing ;tem_ I'.nClosetl - _--_Open --__-- -
1. "total I'loject 'square way he t')l focal Ploicct C'o;t"
I
CITY OF S�1.[zmq jAkSSACHU5E-rrs
Y
l-• 'yy t� E'L=LNGDEP.IR'I1ONT
\\� � 120 W.\SHLYGTON STREET, 31D FLOOR
3l' TEL (978) 745-9595
;<1J(BERiEY Dtt7SC0[1.
FL%(978) 740-9345
NUY01 T110nu ST.PIERAS
DIRECTOR OF puj3LIC PR0PERTY/9L:U_0LYG C0JL\11SSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CIVIR see tian l 11.5
Dcbris, and the provisions of tbfGL c 40, S 54;
Building Permit !k is issued with the condition that the debris resulting from
this work shall be disposed ofinerly licensed waste disposal facility as defined by t�IGL c
l l 1, S 150A.
The debris will be transported by:
� 1 C 2 .DI S'eQ 244
(nama urliautcr)
The debris will be disposed of in :
(narna ot•f'aajtjty) _
(sddras.c of(aciLty)
nature ufpermit applies
I
° CITY OF SM.E,NI %LuSACHUSETTS
BUILDING DEP.1RTJlENT
120 W.ksHLNGTON STREET, Ya ftco.%
\ • T EL (978)745-9595
F.'L'c(978) 130-9844
U�OSFR[ EY DR2S:011.
1dAYOR T Hmus ST.Pmuta
DIRECTOR OF PUBLIC PROPERTY/aurLDNGco.%wmi NER
Workers' Compensation insurance Affidavit: Builders!Contractorr/Electricians/Ptumbers
\nnlleant Infrrrmatinn //A Please Print Legibly
Mime tUmit nsUrgsniratie vinJividual); X'0 ol(Il ;jONC 2 Yee
Address: 3 �/lc�t2 solu L rV
City/Smtc)Zip: f1( 00LC-r0A1 K49 Phone: 7 `0-S—
Flain
employer?Check the appropriate bars Type of project(required):
mployer with 4. [� I am a grncral contractorjandl
ed(full an Uarport-time).• have hind the subcontra 6' NOW construction
ole proprietor or partner listed on the attachedshe1. ❑Remodeling
d have no employees These subcontmctats ha9. 0 Demolition
fur sun inany uapaciry. worker'camp.Insuranc9. Building adJition
rkers'camp. insurance 5. Cl We are a corporation andrequired.) officers have exercised th10.0 Electrical repairs or additions
2.0 1 ant a homeowner doing all work right of axmnption per M11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we hav12.C]Roof r pairs
insuranearequired.) t employees.(No workers' ll.❑Olhee
comp.insurance rcqulmd.
,Nay uppliun deal 01mits bat it must alw 00 uut IN featioa bdavitahowing thak vn,kam'mmpnudon pulley inibrmmlmt,
'I bmeuwneva who submit Ihla u7ldavir indleming thcy an dairy oil work and than hire uuside eantraa:ton mast submit a raw oiltdavit tndicuing rush.
Cuntnvtan that chick this box moat aaauhod m addidumlchat showing she ammo a!the tut!animtaa:bm and thak wurli m'sump policy intermadon.
l sun air rnipluyrr that Is provld/ng workers'rompsitsadan Insurance jor ray rmpluyersc ar/uw la the polt and jOb site
injonnarlon
Insurance Company?Name:
policy U or Self-his. Lic.d: Expiration Data:
Job Slid Address: City/SlatdZip:
Altavb a copy of the workers'compansatlaa pulley declaration puke(thawing the policy number and expiration data).
F`.tiluru to secure coverage as required under Suction 25A of MGL e. 152 can lead to the impw(tion of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and it line
of up to 5250.00 a July igainsl the violator. Ile advkcd that a copy of this statement may bet rurwardud to the 011ico of
In vest igutions;ul'dto MA Pot insurance covcrago vurillcaliun
/du hrrrby c•rrr!y u r rhr pubtr and enulr of perjury/flat Me htjunnmlotr provided above lr true wed currecL
)ate_
0111cfal use uuiy. 00 tray Wile its rah/r urrq to he cuutploidd by city at rownt n/Jlehd
i
City nr l'uwn: __ _ Pvrmft/Lleemc,9
i --'---
issulnil,lulhurily (circio uac):
1. Iluurd of Ifealth !. Iluild)mtl Vepartusvnt I.City/row , Clerk 1. (ileetrieal intpcclar 5. I'lunibinti fntpeetor
b.Other
Contact