119 HIGHLAND AVE - BPA-12-854 3 i ,ao CK -
lA
I --- I'lie Commonwealth of Massarhusclts
Board ot'l3uilding Regulations and St:mdards CITY OF
(IY Massaduuetis State Building Code, 780 C NIR R,•ritrd 'nil
Building Permit Application To Construct. Repair. Renovate Or Demolish a
Urse-or rw o-6im dl Duelling
This Section For Official Use Only
Building Permit Number: __ Date-Applied: _
l✓�L�w �lll� l
Building 011icial(Prinl Mune) Signature Date
41
SECTION I:SITE INFORAIAT
1.1 Property Address: 1.2 Assessors.Nap& Parcel Numbers
I.la Is this an acce ted street?yes no Map Nunthcr Parcel Number
I,] Zoning Informatlont 1.4 Property Dimensions:
Zoning District 14aposcd(lie Lot AreaIs411) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yurls Rear Yard
Required Provided Rcquircd Provided Requircd Provided
1.6 Water Supply:(M.G.t.C. 40,154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Flood
Iona: Outside Fl000d"Lune?
Public 0 Private C — Check if Municipal 0 On site Jisposul s)stem 0
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
N;unu(Print) �— Eiq•,S• a,l.Ip, -%
No.and Stmet reiephone Eonuit Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 1 Existing Building 0 Owner-Occupied O 1 Repairs(s) 0 Alteration(s) Addition 0
Demolition O Accessory Bldg. O NumberofUnits_ I Other O .Spceily:
Drief Description of Proposed Work':
�.iA ��\C�r%(:-y\ � in--vr'Ce�� �L/:i �- ✓'>a-/�i�9zw.. / %L` �-i� ' ice /
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllclal Use Only
(t.abor mod \laterials)
I. Building S 1. Building Permit Fee: S ndicate how t'ee is determined:
0 Standard Ciry1Tuen App tc on Fee
2. Flcorical S / CL7 0
0 Tulal project Cost (Item 6).x mulliplier
1. Plumhiny S 1 Other Fees: S
J. \Icdt.micel ,II\ \(•I S List:
9 \lechaniad tF,rc S — --
�utuesianl total .%I[ Fees: S
(heck No. _(heck .\nttnnit: (',t,h \motmt:
n Tidal Project Cost: S 12 !:CJ ❑ Paid in Full O lhusrmJiny Ital.mee Duo:
gr1,00
i
SECTIONS: ('1)NSfRl1cnONSF.RVICF.S
i.l ('onst�ctiul�i Soprn isur l.icctur(CSL)
/}-ci I Iccnsc Nuulher I �piraluro D.nc
Nainc of('.CL I IaI,ICr I Isi C'SI. l)Ile lice below l._
N„ mid SIrM - ll Unrestricwd(11uddin s tin lu1S,1111UaoIt.I
�---7 -i L C� ��/���//�qLI- t �0✓ 11e,lricicd IR?I'.,mil I)„cllin
Cit%,Toml.Slane.L11' •\I %las,m
Rl' R,n,lin l'a,erin
N'indim .md Siding
SF
I)urning %pph llle!
Insulation
l'elc hone Ilntail address D Demolition
5.2 Rrglst dllo tprusem/entContractor(HIC)
lyre�jj�(C<U/ IIIC Registration Ntunl -r licpirnlic n Wtv
I IIC Comp 11) 'Inc lit I IIC' Itc istrant anlc /�,
s- �l�`"i / J ///s
Nu. a d-S i < �/�r3 Finuil address
Asp � ��</L 7
City/Town./Town.State ZIP rele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.1 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 Issuars 4fthe building permit.
Signed Affidavit Attached? Yes .......... Ct No...........O
SECTION 7s: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.
Print OswaPs Nwne(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 thi.UpplicationjsImeand accurate to the best of my knowledge and understanding. 7
IhimUwner'eur:\ulharired,�gcnt'sNm 'II:IcctrunicSignalun:) Oat'
NOTES:
71. .\nOwner whu obtains a building permit to do his.her own work,oran owner who hires an unregistered Cuntractur
tregisteredinthe Hulne In,provenunl C untractur i HIC) Program),willnu have access to the arbitration
gram ur guaranty Lund under\I.G.L.c. 11'_.�.Other important information on the HIC Program can be found at
,1 n�.r•. �„ '. I Information un the Construction Supervisor License can be found atww„ " ,1p`
2. en substantial Iwrk is planned.pro%ide the information below:
or area I sy. Il.l 1 inCluding garage. tinishcd basement attics. decks or porch)
Cruis Ii%ing area 1'4. It .,__.-. _ Habitable rouni Count
1 \unlbcroflircplacci \untherulhCJnxnns
\onlher 11hathr.wnit . . -- — . . . -- \wnt,crul'hall'halhi
I)Ile of healing i)ilCnl .\anther of decks, porclus
I)I'vof<oohngi)itoll 1711closcd Ifol
l "I alai Proicd ti,(Iflrc Foo1Jy'e 11111% he iuhstittiwd Ilir I',aal Projoct Coil"
4
v �
CITY OF S,V-&Nf, >tiL1SS.ICHC'SETTS
i3CtLDLVG DEP.1ATtEVT
I'0 WASHLNGTON Srxsxr, J A FtOOA
TIM 1978) 741.9593
KRIMERLSy onwou P.Vt(978) 74&934d
MAYOR I}tosw ST.PMUS
DrAECTati OP PI'SUC PRCPIATy/St:MDLNG CO-%US3tONEA
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accardanee with the sixth Debris, edition otthe State Building Code, 730 CUR section III.S
and the provisions of MOL c 40, S 34;
9 w permit M
I is issued with the condition that the dcbris resulting from 1 If. S IJOA.work
shell be disposed of in a property licensed waste disposal racility as deAncd by&ICL c
The debris will be transportcd by:
ln.una ul hauler)
The debris will be disposed Orin :
'fee//
(nameo/raolily)
liddress arrj,rhly)
+ynuuro orpermit rpphcrnt
C[-I'Y OF Siu.Eml II%L1SSACHUSETTS
a BLILOLNG DEP.1WBLE.\T
` ( 120 WASHLNGTON STREET 3"'FLOOR
TEL (978) 745-9595
FAx(978) 7.09844
KIIIBERLEY DRISCOLL
`L�YOA Ttionu ST.Plum
DIRECTOR OF PUBLIC PROPERTY/lIUMOIN4 CO\CUW10V ER
Workers' Cumpensation Insurance AlTidavit: Builders/Contractors/ElectrlciansJPlumbers
lipolleant Infnrmatlna Please Print Lefzlbly
Nainelllmitw,sUrglmrationlndividuall:
Address: i.+f
Cily/State/Zip: Phone M:� l � G� V
,Ire youyn employer!Check the appropriate boa Type of project(required):
I. t[]••ram a cmployor with i. Q I arts a general contractor and I & �Now construction
antployees(fLll and/or part-lime).• have hired the subcontractors
2.❑ lama sole proprietor or partner• listed an the attached sheuL t I. El Remodeling
,hip and have no employees These sub-contractorshave U. Demolition
working tilt me in any capacity. worker$'comp. insurance. y. 0 Building addition
(No workers'comp. insurance J. 0We are a corporation and its
rcquirud.) officers have exercised their 10.0 Electrical repair$or additions
).❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing rupitirs or udditlons
myself.(No workers'sump. c. 152,91(4),and we have no 12,C]Roof mpoirs
insurance required.) r employees.(No workers' 1�,Q Other
sump,insurance mquired.)
'.h�ry upptl.:un dot nha'ukr but rl must also nil uw the vutiuo below.howins their wwken'comprnadun puliq inrLrmullon.
I hvneuwrwn who.Mandl this rnldavil indimins they am doing all twrk And that hit*uu4ide aanrmcsan m,wt nthmit a new amdavil indicting.uch C•intmwun that vhavk this but rnwii ntachal an additiunul.heat,huwing the nurse of the rub•cuntnclwe and their wndeo'sump.pulley inrernudaa.
/urn un rurpluyer rhur 1s prayfainX rvorkpt'cumprnradun lesaranee jot my emp/uyars. Below/s the pulley and fob ilia
irrjunrmden. /
In,urmceCuntpanyVame: �Gff .Uf....���, r7�lw✓j�
Policy 4 or Self•ins. Liu. it: C�t�� GI�G�,1 �%�;. �' Expiration Dale•
tub Site Address: Zz //ry///Arl`/. / KI CilylStute/2ip:_ ". i 4. ,1-(4-,,
/
Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration data).
Kiduro to secure coverage as required under.Section 25A ut•MGL c. 152 can lead to the imposition of criminal penalties of a
tire up to 11,500.00 undlur one-year imprisanmcnt,as well as civil penalties in the form of STGP WORK ORDER and a line
](up to 5250.00.I day Igainst the violator. ile advi.;ed that a copy of this,tateotent may bu turwardcd to ilia OI'licu of
Invc,ligatiuus„i the MA 1lariosunncc coverage vest ticatiun.
!du/rrrrbyr c r y rrnJer Ilfrpuini u prrrU7r7r'?i.,rjpvrjury r/rue the brJurorurlmr pruvrJeJabove,yv Irue rJ corrrce
IJ//icial u.,e only. /7a,rue write Ls/h4 area, to be cuaryleted by city ur taros o/jlciai
Cily nr 1'tnvu: . __ -_ Pcrmitif.lectae i
h,uia-Aisihurily (circle -...-_ .
I. lluard ul ileailh 2. ILtildlnp Ocparlutanl I. ('ityi I'uwn C'terk 1. "teetrlcal hnpec Ptr i. Plunthin;; fnlpeetor
G. ILhcr
I
l'n tlad I'ennn: