28 HAZEL ST - BUILDING INSPECTION CITY-OFS-ALENI -
PUBLIC PROPERTY
DEPARTMEINT \w
IJ\ME11LfiY DRISI:W L W
MAYOR 120 WASHING"Sn LEEr*SNXa1,MA15AC3il;5tT1S 01970 C
1FL 975-745-959S*Fnx:97&740.95"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property-Address— / - --
1� e l Sl
Property is located in a; Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land xy�
Name: Mlc e.11t Uc rl
Address:
Telephone: 4-7 g— -7 u y—
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
ce- LA_)I clottis�
Mail Permit to: 3Y5 Ste; �u 76 rc� .-� M� 0 1 &o-7
What is the current use of the Building?
Material of Building? v--'A r az' '> 5 If dwelling. how many units?
Will the Building Conform to Law? ` Asbestos?
Architect's Name
Address and Phone
Mechanic's Name } tab- 5L9 Sc-7
Address and Phone ��u"5 l/V-w " w ov `'F r A 5c-U a"-
Construction Supervisors License
��# HIC Registration#
Estimated Cost of Project$�S fSLSZ— Permit Fee Calculation
Permit Fee $ �C - Estimated Cost X$7/$1000 Residential
— -- - Estimated-Cost X$11/$1000-Commercial
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build tothe above stated
specifications. Signed under penalty of perjury X 6ez- �
Date !a- rya`
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PUBLIC PROPERTY
DEPARTMENT
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' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
�? rl 600 Kashington Street
�= Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affida-dt: Builders/ContractorsTlectricians/Plumbers
Applicant Information Please Print Legibly
raffle (Business/organization'Individual): T)t+F'-�/
i
Address: ��`��4 12t1t
City/'State.Zip: XZZ c G Phone ': (\—1�c- `j UA--e)-. to l,o
Are you an employer' Check the appropriate box: Type of project (required):
1.SE I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
n r listed no the attached sheet `+ Remodeling
a.Ti a aG iC prG}yictor or partner-
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers` comp. insurance. 9. ❑ Building addition
[.No workers' comp. insurance 5. El We are a corpora[on and its I0.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions'
myself. [No workers' comp. c. 152. §1(4), and we have no 12.❑ Roof repair
insurance required.] t employees. [No workers' 131.❑ Other
comp. insurance required.]
'Any applicant that checks box yl must also fill out the section below showing their workers'compensation policy information
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidaNit indicating suclti -
-Contractors that check this box must attached an additional sheet showing the name of the sub-connectors and their workets' comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy?and job site
information.
Insurance Company Name:
Policy=or Self-ins. Lic. n �p n k [X1 Ci :L--) Expiration Date: l—07
Job Site Address: City/State/Zip:
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 MGL c. 152 can lead fo the imposition of criminal penalties of a .
fine 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 fine . .
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under thepains andpena/ties ofperjury that the information provided above is true and correct.
Signature t A A 4 Date
Phone
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#: