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17 HAZEL ST - BUILDING INSPECTION (2) The Commonwealth of hfnssachusetts }yam Board of Building Regulations and Standards CITY OF 1jf Nfassachusetts State Building Code, 730 CNIR SALEN( Ravfsed M1ktr 1011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or five-Family Dwelling This Section For Official UsisOrily. Building Permit Number. Da"Applied' Building Official(Print Naine gna Date SECTION 1:SITE INFORMATION 1Ll P op t���Addre s: 1.2 Assessors bfap Parcel Numbers 1.1 o Is this an accepted street?yes no bfap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Are&(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:(N.O.L c.40,§34) 1.1 Flood Zone Information: 1.3 Sewage Disposal System: Public❑ Private❑' Zone: _ Outride Flood Zone? Check if yes0 Municipal❑ On site disposal system ❑ SE`CTION2;' PR0PERT$•OWr4ERS10 2. , p wnerto R c rd. IQro r- fi(°l({ PSf el( P1/!Q� �15 y M,� 2-140 Name(Print) Ctry,Stat0.ZIP 5� `PoWeV 121" krin �mU>^D 2-0-2- a- Woc) �it1rt'�If1A_utmtel'C((aLi COY" No.and StreetZA s Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKs'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ NumberofUntts_ Other ❑ Specify: Brief cript(o of Proposed lV k : C> ,7/ C C 1 ^rA- SECTIOt`f 4: E TIVL4'IED CONSTRUCTION COSTS ItemME,01,,,Estimated Costs. I Libor and Materials Official Use Only 1. BuildiS D .� 1. Building Permit Fee:3 Cndicata how fee is determined: ?. Mcctrij C1St.•tndaid.C VrowrtApplication Fee, ❑'CotakProjectCost'(Item6)xmultiplier x 1. Plumbi ; Other Foes .St. .\lachan List:_-- _---- Total All Fcrs: iChock No. Checic,\utowurfntil V ---- 0 11.1id in Frill Cl t)utstawlim{ 111111:e, I)+ic srcrunv r-oNs,rRUCrluN SERVICES 5,1 Construction Supe visoNlr License(CSL) 0 d U � Lia ro nst Number Gepiratiuo Da hunt of csL III deer 111777 �/ List CSL type(set below) Tj c! ) I((,1/ t' rype Description No. and Street U UnrestrietcJ Buildin s up to 35.000 cu. R. It Itcsuicted I&3 I*aInlix Dwellin nr City/ru,vn,State,ZIP Rl �oofill RC Ruutin Cuverin WS Window aad Sidin SF Solid Fuel Burning Appliances �( Q 3 e4 7 �G� f Insulation Email uddras D Demolition 5;l hunt / o S`y�' / 7/ `l $, Registered Hume Im rovemeat Contractor(11(C) � b�L tliCRegistrulonNumber Expiration Date ,,,CC nyr alne or Flit. Rytiis�`ItN rr� (i� / s Email address No anA(rr�tt� t/ i�G✓ 'e, /LL.i lA72dt"'A A(V Ci /Town State 'LIP Tale hone SECTION 6: WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 151. g 15C(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 .......... 0 No.......... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COdIPLETED WHEN OWNERIS 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 bu• ding permit application. 1, 1'JU i v tt.r nro Print Owner's Nama(Electronic Signature) SECTION 7h: 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. I`rint Owner't ae Autlturiecd:\;ent's N.unt(Eltctrunic Signature) Date NOTES: I, ;\n owner who obtains a building permit to do hivher own work,ur an owner who hires an unregistered cuntrnctur (nut registered in the dome Improvement Contractor(HIC) Program),will t have access to the arbitration pro,r:un or guacunty land under M.O.L. c. 142A. other important infunnatiun un the HIC Progrmn can be found at tI ww nru< .:uv%or.I OlFunnutian on the Construe Supervisor License can be found at utvw ncts.,.� I 2. When substantial work is planncJ,pruvi.lu the infurm`ti`njthtlu1l'iga, Finished busemtnt/:utic;,decls or porch) fut'I, titlUf:IfC:1(itl. It.) ______ —( "' Ifabitlble room count __ Untsslivingarea(sq. 111 -- Nundturofbcdrrnnns _— - �bnnbcroftircplaccs ..__ -- -- — - —--.----- Nnwhurs,fh.tltb.uhs Vwnhcr of h-uhrrnlws .. - .. ---. . .--_---- I'.I)d t�f h::uiut; ;y<:�nt _ __ _ _ ?aunbcr of Jccl,.,'.' {'nri tat .--__-- --- rnda;cd pelf I'',Ia ..Icoolim, : .lent .. . __ -- -- — -- -- { I-• i it l'n q.'.t � In lr•: 1 f I•;i Ill.ly lto alh.ntnt: l r0i 1.,LI I'njal l i_f' .- I h �0'�•�. CITY OFS4UZNI, i-Au ACHUSETTS i ! 1)t:MDLN(; 0EPAAT-M&NT tyr 120_0 l•V.13HcVGTON STREET }"aOOR 1'L (973) 743-9595 <1m0ErtLEY DRISCOLL F%-X(973) 7•I0-9344 ,bUYD:t - TFta5613ST.P1EA1lt3 ❑IaECTOR UP pt:OL1C pROPFATy�BCILDLYG COSL�tlJSlO.V ER Construction Debris DISP0331 Aff7davit (required for all demalition and renovation work) to accordance will, the sixdt edition orthe state 13uilding Code, 730 CtbfR section 111.3 Debris, and the provisions of tMGL e 40, S 54; ©wilding permit)w this work shall be is issued with the condition that the debris resulting from I l I, S l JOA. disposed o f in a properly licensed waste disposal facility as defined by tV[GL c /The debris will be musportcd by: btarssa ul'ftaulw) The Hubris will be disposed ot•in . --- Nimcatncdity) +ipwmrclil crmit.lp . iamt a CITY OF S:�L &N1, NLNS&: CHUSETTS BUILDING DEPAlk-MENT 120 WASHINGTON STREET, 3w FLOOR •ILL (978) 7.45-9595. F.Ar(978)740.9846 KI.N[BERL.EY DRISCOLL THOmAS ST.PIERRs Nv1AYOR DIRECTOR OF PUBLIC PROPERTY/BUtIDiING CONMISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information / Please Print Legibly //_� Nalnc(Busi,%s&organizatiorvindividual): v n �A41, it g Address: 2� 12.L�� City/Stateizip:bflyL (:Y Qr:1 �-/P- Phona lk 6(j 3 S-i: 7 Xolr?) Are you an employer?Check the appropriate box: Type of project(required): 1.01 am a employer with 9- 4. 0 I am to general contractor and 1 $. ❑Now construction employees(full and/or part-time).* have hired the subcontractors 2.0 lam a sole proprietor or partner- listed on the attached.sheet t I. Remodeling ship and have no employees These subcontractors have g. ❑ Demolition working.. for me in any capacity. workers'comp.instirailce. 9. ❑ Building addition (No workers'comp.insurance 5.0 We are a corporation and its - rcquircd.]. officers have exercised their ME] Electrical repairs or additions 3.0 t am a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions _ myself.[No workers'comp. c. 152,j 1(4T,anti we have no 12.0 Roof repairs insurance required.]t employees.LNo workers" I3.❑Other comp,insurance required.] -Any applicom that chocks box et must ahw rill out the suction below showing their wmkius'compenWioo policy infurmadon, , t I Ianeuwnats who submit this atrldavit indicting they am doing all work and than him outside contractors mml submit a new afndovil indicating such =Conuadurs that chock this box mutt atochod an addilfunal ahml showing the name of this subcuntmdon and thafr workers'comp.put Icy infotnuaon. firms an employer rharls praviding workers'comparradon Insurance for my employees Below is the policy and job site h1farmalion Insurance Company Name: 7� Policy 4 or SclRins. Lic.d: [''_SA/\ .V/J "0 aC , /L `¢/�9P pimtion Date: �7 t Y— to, lob Site Address:17 /"r�Z�� J � City/Slate/2ip:_� 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 NMI.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 a STOP WORK ORDER and a line of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigaduns of the DtA for insurance coverage veritication Ida hereby t er y t +der the p its and pen allies of perjury that the information provided above • Irue Via correct. OJjlcird use only. Do not write in this area,no be compieted by city er town njjlelat City or,rawn: PermitILIcense Issuing Aulhority(circle one): 1. Board of Ilealth 2. nuilding Depart n tal 3.Cilyfrown Clerk 4, Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: - _ Phonet!• [