33 HILLSIDE AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
�- Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, $dar g Cd 780 CNIR M
Revised:Liar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family D vellin
This Section For For Offlciol,se Only
Building Permit Number.:- Date lied: -71
` f
Building Official(Print Name) Signat Date.
SECTION 1: S[TE l KQRSIATION
1.1 Propert A ldress: 1. ssessors Map& Parcel Numbers
33 0Z' e P�
1.l 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 (ft)
Front Yard Side Yards Rear Yard
Required Provided Rzquired 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 OWNERSHD?L ''.
2.1 Owner'of Record: C
V-e�s.r JOVIes J�r�e^� ✓fin v* i , Cj-70
Name(Print)` City,State,ZIP -
33 A, Aso tic < 7S1 G53 ONIOA
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORk check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-
5
cq
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Item Estimated Costs: Official Use Only.
Labor and Materials
I. Building $ L Building Permit Fee Ii Indicate how fee is determined:
❑ Standard.City/'town Application Fee .
2. F,Iectrical S ❑'total Project Cost' (Item.6)xmultiplier x
3. Plumbing S 2. Other Fees: S �( \
l. :Mechanical (IIV:\C) S List:
5. \lechanical (Fire
fin : cession) 5 'total:All Fees:.S
Check No. Check Amount: Cash ;Amount
69 I ntal Project Cost: S 0 Paid in Pull ❑ Outstanding B:dance Due:
N4
t' 9
SECTION 5: CONS'I-RUCTION SERVICES
5.1 Construction Supervisor License(CSL) w1 60-,\
License Number Expiration Date
Name of CSL[folder U
`^ List CSL Type(sae below)
\ e wcr C)
No. and Street Type � Description
U Unrestricted(Buildings up to 35,000 cu. ft.
Fit
lkAA O\C't ` 0 R Restricted MI Family Dwelling
City/Town, State, ZIP bf Masonr
RC Roo tin Coverin
\VS Window and SI(I"I
��^.�N,. SF Solid Fucl Burning Appliances
e1 y 1`-L ( ( uc) \Y "'1 �� ..f1�`�2 `c"`"`� [ Insulation
rcle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC) I" � Ot o
—;�>C.. <)MK 'f y2c- .J--I,- HIC Registration Number Expiration Date
l II Cumpan Name or II[C Registrant Name
No.a Str t. Email address
ce� ,�, .+�t\R cStS z o �t74 � "�I l�tJtJ
City/ own, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denied of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... b'� No...........❑
SECTION 7a: 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 Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, [ hereby attest under the pains and penalties of perjury that all of the information
contained in is application is t e an ac urate to the best of my knowledge and understanding.
Print Owner's or Authorized:\gent's Nine Mectronic Signature) Date
NOTES:
I. 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 H[C Program can be found at
www.mass.gov,'oca Information on the Construction Supervisor License can be found at w% wminass.eo�rdL
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.)._ (including garage, finished basement/attics, decks or porch)
Bross living area(sq. ft.) _ Habitable room count
Number of fireplaces_ dumber of bedrooms -- --_----
Number ofbathrooms Number of halbbaths
1)'pe of heating systcut ----- --- Number of decks/porches
I' peofcoolingiy;tcin -------_------_---- Enclosed_ - ---__-__Open
"I'ttal I'roj�•a Syuura Pxxa,e" usty be sub,tihitcd t;u'I'nrtl Project Co,t"
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CITY OF SiU E`,I, NLkSSACHUSETTS
i3UII.DLIGDEPARTMEINT
130 VV:ISHLNGTON STREET, 3'FLOOR
T EL (978) 745-9595
KIMBERLHY DRISCOLL F•'LX(978) 740-9346
i,L.%YOR Tmo.%w ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUanLNC;COSL\IISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of tile State Building Code, 730 CMR section 1 I
Debris, and the provisions of MGL c 40, S 54; I.5
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 I fGL c
111, S 150A.
The debris will be transported by:
�H 51-C, to
(name of hauler)
The debris will be disposed of in
Uv V✓ S.cl� CC,
(name of facility)
ANA
(Jddress of Facility) /n1
signature of permit applicant
-2)
date
t
1
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CITY OF SMLE.Nf) NvL-1S&: CffUSETI'S
BUILDING DEPARTMENT
120 WASHIINGTON STREET, 3}e F100R
Dy� TEL (978)745-9595
F.uX(978) 740.9844
KIN[BERT RY DRISCOLL
�UYOR THomAsST.PT ua
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COSLNIISS(ONER
Workers' Compensation insurance Affidavit: Builders/Contractors/ElectriciansiPlumbers
Applicant information p -I Please Print Legibly
Narric(Bmiir yOrganiratiouIndividual): VIC ,
Address: O
City/State/Zip: �e PhoneM: g10 ' ` " t l0o
Are you an employer?Check the appropriate box: Type of project(required):
1.Cl I am a employer with 4. 0 1 am a ganrral conteaclot and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sut►contracicrs
2.0 1 am a sole proprietor or partner. listed on the attached.sheet.I Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.Insurance. 9, 0 Building addition
- (No workers'comp. insurance 5. 0 We are a corporation and its
required.) officers have exercised theft 10.0 Electrical repairs or additions
3.0 1 cam a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or udditions
myself.(No workers'comp. c. 152,41(4),and we have no 12.0 Roof repairs
insurance required.) f cmployees.[No workers, 13.0 Other b\tv--a—
comp.insurance required.)
•nny applle:ua thug chccka box e I must also all out the u<lioo below ahowine rha4 waken'compenudon ponry inlbrmallon,
'Ihvnuuwm"who suhmit this atild'avil indicating they are doing all work and thce hire outaidecontmaers must mhmll a now alrldavit indicating suds.
:Cuntrxten thol chuck this box mutts mtachod an a"eunef Awl showing the name of the ndscanuse re and thole w,Aas'mmp.polity infotmadoo.
l urn an employer that is providln,y workers'cornprnradon Insurance for my employees: Below Is the policy and Job s/h
information _
Insurance Company Name: ` YV-\
11ollcy4ur Self-llls. Lie.H: cl— Expiration Date:
lub Site Address: 75) O's\\S-j e ✓a.R Citylslate/2ip: C)`91 O
Attach a copy of the workers,compensation policy declaration page(showing the policy number and expiration bate).
Failuro to secure coverage as required under Section 25A of MGL a. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S330.00 a day against the violator. Ile advised that a copy of this stalcmunt may be forwarded to the Off ice of
Investigations ul'tho DIA for insurance coveralls wrifiealiun.
/du lrrrrby e•rn!y mrJar darns un I rrro/ a ufprr/ury that the Grfurnrurlon provlJrd above is true and currrrt
Siena it re' , �h _moo Da(u: 3��" `3
Phone d; 01 -1 i•3 `� `-^ 1 \7 (X�
O1Jia•iul use only. Donor write in r/dr urr,:4 to be campleted by city ur lawn uJJlelud
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CiryarTuwn: __ . ,_ Permful.IcenveAl
iIssuingAulltnrily (circlo one): --
1. Uuurd of llcalth 2.Building Ilepartment .1.Citylfnsva Clerk 4. Electrical Inspector S. Mumbing Inspector
6.QUmr
Contact Pernnnr. ... _... _.. Phano Il: