22 HAZEL ST - BUILDING INSPECTION I'he C'ommliomecal(h ul Nfussachu�ctts
y; Board of Building Regulations and Standards CI'11' OF
s�. '035sachusells State Building Code. 780 CNIR SALE.\1
Building Permit Application To Construct. Repair. Rcnuv;tte Or Demolish a Rel
())n'-or rmv-kamdr Du ellnkV
This Section For Ot33ciul Use Old
Building Permit Number: Dal Ap lied:
Building Ullkial(Print N;unejZ-- Sigttalure Dula
SECTION I:SITE INFOR ATION
I.1 Property Address: 1.2 Assessurs.Iap di Parce Numbers
Via- NAzr;t_ S'
1.la Is this an acce led street?),es no blap Nunfhar Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
v
Zunins 0(suict I'l,"puscd,T, Lot Arco(sq III Pronloge(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c. 40.§») 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Niblie❑ Private❑ Zone: _ Outside Flood Zone?
Check if cs❑ Municipsi❑ On situ dispusut s)stem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 wnerl of Recur :
�L�F( y 1�NtS S�L//)l ✓F alter? 6
N;ww l l'nil - ('iq•,Smte.l.IP
J- 4�IRZ� L .5C �/�8�lG
No.and Slree' fdephuna tined Addn:ss
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Ex(stinii Building Owner-Occupied O Repairs(s) Alterallonls) ❑ Addition ❑
Demolition ❑ accessory Bldy.❑ Nuntberof Units_ Other ❑ .Spcval :
Grief Description of Proposed \Vork°: 1 I AL of
iU Tixt/icE cd ) UJ .a� 0(oN L st/ Ae /'tc
CAUM&44
SECTION J: ESTIMATED CONSTRUCTION COSTS
Ilcits Estimated Costs:
Labor mtd.Materials) Official Use Only
1. Building S /0 Oao � I. Building Permit Fee: S Indicate how lee is determined:
2. lacctrical S ❑Standard City+Tussn Application Fee
S
❑Total Project Cost'I hem O x multiplier l 7. 1'Itunhiitg ' — - -- —
_. Other Fees: S-
4. MM1,11tic.11 ill\ W) S List_
\(cch.mwA iFire -- ----... ------ . . .
I `u +rnuionl S ro(al
n Tidal Project Cuel: S U ('heck No.
❑Paid in Full O(lutslauding 11al•mcc Due:
r
St.("PION S: ('ONSrRU("rION SERVICES / L�
S.1 ('unstructiun Supervisor License ICSI.I � Mile
I iceue�Gl tUt r plrali n I)MIW
Nanwoit.SI. IR,l,lar ......__—_ ImCSLI')puhechelultl.__._—
I')Pc Ikscripliun
No. d''Id 51re¢l ---- , - -_ -- tl I4lrcsuia.dtlhulJiu fli toly,nll2al. IL1
m4 µ IL¢etri.kJ Ia2 p.lmil Dl�dlin
--�— %I 'Slosun
Cipil'ua n,titale./It. µIC µpolio CoNcrin
µ'S window,wd Siding
SF Solid Fuel Ilurning Appliances
I Insulution
Itnluil nJdress U Denloliltnn
41.k
i,2 Registered Ilume Improvement Contractor(HIC) r
V C f I d' L��(/ �/js IIIC' I(eglsl r li nrul' m Date
♦tj � �/
IIIC Comp tl Nanlc or I Ill.' R.gulrunt Na11W
,
)�L I L''ma11 address
No. 1 Street /
L, c hung
Ci ITown,State IP T.I
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C. 152,I) 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atfidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........R✓ No -
O
SECTION 71l: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
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.
Dote
print gwner f Nwne IElectntnie Signuluro)
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
colita'tied in this application is true and accur to to the best orply knowledge and understanding.
�� ✓L�Lt� 2� �7
D e
l`rllll Ownef'f ur:\ulhUri/ed A�elllb Nilllte Ilile'lrnnle Ci gllalafe
NO' ES:
I, ,\n Owner whu obtains a building permit to do his her own work,ur on owner who hires an unregistered cuntracwr
Inut registered in the Hume InlprovententContmctor(HIC) program),will nu have access to the arbitration
program or guaranty fund under\I.G.L. c. 142.4. Other inlpunant information on the HIC Program can be IUund at
„w,l -,.I Inronnation an the Construction Supervisor License can be found at2.
\\'hen substantial work is planned, pruvide the information below;
rout flour area Isy. It.l - ____.._)including garage. finished bascmcn(attics,decks or porch)
Habitable rount.ounl
Gross living area 114. ll.l ---.. -- - - Number of bedrooms
\wut,er of lircpla.es .. .. —_ Number of hall'hall"
\unlherol'hathrounls \luntlerofdc.ks, pardlcs
I pe al he.lting i)+I.n I ndu,.J ))pen
„f.OUllllg i.U.III
I
l "I,n.J ProicO Square 1',hndyc Ilt;l\ he soh+ulutcd Illr Total I'rojal Cost"
r
CITY OF S.u.E,Ni, NLISS,kcfiL:SETTS
JLLWLNG DEP.IATIE\T
1 _'0 W-UHNGTON STAW, )64 FtCCA
rEL t973) 141-9591
XIUMAI Y OUXOLL F.Vt(979) 1a4984d
NCAYOR fHo.►4v ST.PtEsig
DIRFCTOti OP PL SUC PROP IATY/at;MDLNG COUAIISSIOV ER
Canstruction Debris Disposal Affidavit
(required for s0 demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 1So CbiR section 111.J
Debris, and the provisions or,4tGL a 40, S J4;
Building permit At is issued with the condition that the debris resulting from
111 work shall be disposed of in a properly licemed waste disposal facility as defined by,blGL e
1 I I, S 1 JOA.
The debris will be transported by:
(n.una ut'heuler)
The debris will be disposed Orin :
P(name or facility) fli C&
(rJCr vorf�.d'rY1
fn�Nre ur;er if p Iwaaf
CITY OF 5, .EM, AkSSACHUSE"ITS
�1 J BUILDING ❑EP.tiAT>t-\T
120 WASHLNGTON STREET, JVa FLOOR
y TEL (978) 745.9595
Rvx(979) 7 k19844
Kl.113F: I Y DRISCOLL
A{Yo Z TTioaL►s sr.PIE.aAB
DIAECTOA OF PULIC PROPERTY/OI:MONG CO>LVISSIONER
%Vorkcrs' Compensation Insurance A171davit: Builders/Contractor*/Electricians/Plumbers
kilolleant Informutiots Please Print Lelihly
V;I I11C lDusioc,vUrg,tmrariamindividuull: 1604e O(W
i Address:
City/Statc/Zip: Cj bo phoneN: E9
�l`ree/you un employer!Check the appropriate boat 'rype of Project(required):
1.L,(Q (am a employer with 1, Q I ;un a gametal contractorjdl
6, Q Now,cumuuction
unploycea(RIII and/or part-time).• have hired the subcamn
2.❑ I am a sale praprictar ur partner. listed oil the attached sheI. ❑Remodeling
.hip and have no employees These subbeontmetors ha8. Q Demolition
working liar me in any capacity*
workdrs'comp.insurancy. Q Building addition
(No workers:camp. insurance 1. Q We are a corporation and
requircd.J officers have dltdmised th10•0 Electrical repairs or additions
).❑ lain a homeowner doing all work right of exemption per M11.Q Plumbing repairs or additions
myself.(No workers'Gump, e. 1 J2, 11(4),and we hav12. / toorrepaininsurance required) t cmpluyees.(No workers' Ij•Q Other
Gump.insurance required.
r.hny.ipplh:un Jar ehwka but of mwt,lwa nil uu1 tha aveliue bolo*allowing chair"*am,Compensationpolicy inarrmmlon.
I Lvnauwn o who,uhmil this 41rdavil indlearing ihey am doing if,,wrk and than hits oanide eomneten Imas ruhmit s naaw alRJavil indleming aveh.<',�mcytun thal,lawk'his box mud maehal an aJdnlurud.hart ahuwing the nwoo ar the mb.jarMtor a and hair woAare•comp,policy intonnadan.
fain con ratpluyrr Thar/r pruvldlnX lvaraFtra'cumpeua/un Insurance/or.my nnp/uyevst Btlaw/s the pol/cy and job site
in/argrullnas, /1
I n..urulce(:umpany Natna: �//l`Q7`� /l�f U�(/Y[" l A/5
Policy VorSclrins. Liu, rl: WC-1 —,3(S ' 331S2 L/1 (- EApirution Date:
Job Sild Address:2,;- kl/y,(f'L Cityi StatrrZip; Sfi2- /Vlf} ��7�
.�ltacb A copy of the workers'componluloo policy declaration pigs(showing the policy number and expiration data).
h'.lilunt to,ecure cuvemge as requited under.Suction 2JA ot',%(GL e. 152 can toad to the imposition of criminal pdnaltids of s
final up to S I,500.0 und/ur ale-year imprixnnment as well ax civil penalties in the Porn of a STOP WORK ORDER and a tine
of�.ya ua M0.00 s Jay against the violamr. 11e advised that a copy ul chit 14tumcni may be iurwardcd to the Gllicd of
1.1 vc,li gal iuns,d I he n1,% for iniurance tovcr.igc veri ticaliun.
/do hereby reel/ly raider dtd p nl cold penvltlr.i�a/perjury Brut the in/arnrml0at pro YiadJ J uve/l't rrud'aid cuffle
0/h i4lme.na1y. /lvn✓t'.vittinl/dr urnr, ro Ift curuplddd by Lily ur lu11411/jlriu!
City ar I'uvn; i'crmiul.lccnte i
I•.uiny.\Whorily (rirclu nne): --._ _'-
I. ;loard.al 11rA14 i. Iluildln", I)i p.vbrnmt Y, ( sty;h nul Clerk 1, 4:Icetrlril lii,pcetur i. Plnmbin{ (an Paetnr
G, nth<r
l.nnl.a�l i'rnnn: