123 HIGHLAND AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
rY OF
Board of Building Regulations and Standards CITY S M
Massachusetts State Building Code,780 CMR
Revised dMar Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
\ One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: ate Applied-
4.
e�
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
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1.1 a 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(11)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
Oho r�I
/-> ofi�t�
I�a'me(Print) GC�ity,State,ZIP
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No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKz(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief 1De``scriptio of Prrpoposed Workz: ' h r CE
�!: tLL �CF V 36>` .1 S CV^0-
v2
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard CityfFown Application Fee '
2.Electrical $ 3
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: `
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ l D OQ ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5 CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 210 /3
License Number Expi m ate
�e oN S Holder
List CSL Type(see below)
ce Type Description
oan Street
2O U UnresRestricted
1 (Buildingsm u el ing cu.ft.
_ ✓ R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Qitc/rCacJ$�✓�SCpfi � (owl Insulation
Telephone Email address D Demolition
5.2 ,Registered Home Improvement Contractor(HIC) 1�G 4%a 3 /
/acy HIC Registration Number cpi.tion Date
Hft ompa�y ame or HIC egistrant Name ,
�//7 // .sue �� Glhl�ie S�{'c✓L'riSLc�t�� mar, •COJw
Nkmarlpl 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 .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Anl.CJ'
I,as Owner of the subject property,hereby authorize � S-/�L/f,�,O'J5 (�!/
to action my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) D to
SECTION 7b:OWNEW 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 inthis application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/di)
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
1 i 1
CITY OF S�U.&N4 2UNSSACHUSETTS
BI:IIDINIG DFpARTJtENT
120 WASHINGTON STREET,Y°FLOOR
T L (978) 745-9595
FAx(978) 740-9846
SiBFRi EY DRISCOLL THONW ST.PIERRE
MAYOR DIRECTOR OF PUBLIC PROPERTY/BI ILDLNG CO%MMIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansiPlumbers
Applicant Information Please Print Legibly
Name(Busirwsoorgamzatiatwindividual):� �� �1�--✓CAS
Address:_1l /.t//,19
City/State/Zip:Z21- dd e 1"e `nA- /r/1f319one n:
Are you an employer?Check the appropriate box: Type of project(required):
1.10 1 am a employer with- 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet: 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in an capacity. workers'comp.insurance. q
y p ty. [1 Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,41(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 13.❑Other
comp. insurance required.]
•Any applicmt that checks box dl most also fill out the suction below showing their arorken'compen>odon policy information.
s 1 Lxrteownera who submit this affidavit indicating they ate doing all work and then hire outside contractors must wbmit a rtew atrdavil indicating such.
:Commtylan that check this box most muched an additional shoe[showing the na ne of the sub•vouactors and their worker'comp.policy infnmtation.
lam an employer that is providing workers'compensation basarance jar my employees. Below is the policy and fob site
information.
Insurance Company Vame: /� � �s �fISU✓ltr.�� f/ //,�
Policy#or Self-ins.Lie.M blACFI 7^,7V-3 Expiration Date:�l
Job Site Address: //i�h�n�i�l/� City/State/Zip:,, /L e--e,9,,26
Attacb 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. 132 can lead to 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
/do here nrt side pains and p5sliallies of p rfary that the information provided above is true and correct
Sienatur S G Date: 1.o114111
Phone
Officiai use only. Do not write in this urea,to be completed by city or town off/ciat
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#:
144"
24" 12" 30" 1 , 76''
7 ' 73"
1" 55;" 37,"
38" ,' 3 ' 24" 3: 18" ,
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All dimensions_size designations This is an original design and must Designed: 9/15/2011
given are subject to verification on not be released or copied unless Printed: 9/15/2011
job site and adjustment to fit job applicable fee has been paid or job
conditions. order placed.
rg andy Steens highland ave Schrock kitl All Drawing#: 1 I No Scale.
CITY OF S. .E;N1, NLAsS.A.CHUSETTS
• BUMDLNG DEPARTMENT
a 130 WASHNGTON STREET, 3'°FLOOR
8j T EL (978) 745-9595
FAx(978) 740-9846
KI,tgFRT FY DRISCOI I.
MAYOR TH016US ST.PW2JM
DIRECTOR OF PuBLic PROPERTY/Bul[LI) NG COMMSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
date