37 HILLSIDE AVE - BUILDING INSPECTION�
, �
, � � The Commonwealth of Massachusetts
�k � Boazd of Building Regulations and Standards CITY
y� O Massachusetts State Building Code,780 CMR,7`�edition R�ed�amr�
(�'I � Building Permit Application To Construct,Repair,Renovate Or Demolish a l, 2008
I� One-or Two-Family Dwelling
Tltis Sectio For Official Use O
Building Permit N ber: Date Applie
Signature: �` /� � � �` .
BuildingCommissioner pe orofBuildi Date � � � � .
� SECTION : I INFORMATION
1.1 Pro rty Ad ess: ��� 1.2 Assessors Map&Parcel Numbers r�
' :3���!, /�s i d.�
t.la Is this an accepted sffeet?yes no Map Number Parcel Number
I1.3 Zoniog Intormation: 1.4 Property Dimensions: �
Zoning District ProposeA Use Lo[Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Frant Yard Side Yazds Rear Yard
Required Provided Required Provided Required Provided ,
. 1.6 Water Supply: (M.QL c.4Q§54) 1.7 Flood Zone Information: t.8 Sewage Disposal System:
� Public❑ Pmate❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'otRecor : I� � _S� � 3� /�i//si�,�
{� SHI� 0l�7
Name( ' Address for Service:
SC 1�5�-7�f5=��7�
�gna Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repaire(s) ❑ Alteration(s) ❑ Addition ❑
Demoli[ion ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brie Description of Propos Worlc2:
��.�.� � l�C� � �1 � Ann� ��.-r �
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ �� I. B�ilding Permit Fee:$ [ndicate how fee is determined:
2.Elecfical $ � � ❑Standazd City/'I'own Application Fee
❑Total Projec[Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ , �j
4.Meohanical (HVAC) $ List: /�/��
5.Mechanical (Fire $ � �
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ '� � Q ❑p�d in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 LicenSed Construction Supervisor(CSL) . �/
„�..e�t ,SLI� ✓ �"�z Lice Number E�cpirationDate �,T
�i CSL-Holde � � � v
fa�x 6�ss" nn.d�r.ra�. r�,� nl��fry ��src�s�f,���'�e �ow> 2—�S a
Ad ss ' T e � Descri tion
U Unrestricted u ro 35,000 Cu.Ft.
R Aestricted 1&2 Faznil Dwellin
Sign M Maso Onl
9 7�I RC Residentiai Roofm Coverin
Telephone WS ResidentialWindowandSidin
SF Residen[ial Solid Fuel Bumin A liance Installa[ion
D Residential Demolition
5.2 RegisteredHomeImprove�ontractor(HIC) �j 7Z� �
FQC C y or HIC Re isVant N � Registration Number
__� 'x a�.� �v Cr--Q�'-�-YIC Z-'/�7—�fp/ �
naaress �
- � �''/71` Expiration Date `
Signa[ute etephon�
SECTION 6:WORKERS'COMPENSAT[ON INSlJ2ANCE AFFIDAVIT(M.G.L.c. i52.§.25C(�)
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
I, � /} S G cb as Owner of the subject property hereby
authorize � f.�' ���., ,. TI—T to act on my behalf,in ali matters
relative to work authorized by this building peanit application.
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� a of Owner Date
SECTION 76:OWNER'OR AUTHORIZED AGENT DECLARATION
I, �q� 1M�M.c! J'2 W1�.,�.c� ,as Owner or Authorized Agent hereby declare
that the state ents and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
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Print e /
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Signa er Authorize Agent Date
Si e der the ms and nalfies of
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)Progam),will not have access to the arbitration
program or guazanry fund under M.G.L.c. 142A.Other important information on the H[C Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR RegulaTions t 10.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basemenUattics,decks or porch)
Gross living azea(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathtooms 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 CosY'
� CITY OF S.1LE�,�[, I�L�SS.�CHL;SETTS
, Bl'ODLYG DEPARTtE�iT
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DIItECTOI OF PIBL[C PIIOPERTY/OCQDLVG CO�L�RSStONEt
Wurkers' Compensation Insurance �1tTidarit: Duiiden/Contr�cton/Electriclyns/Plumben
�unlleant Infarmattoe Plcrx Print LeaibiY
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V�me �e�,��o.��:���otii�,���a�l'��5 � �` �'l^�-c�vv�_4' l-�(._f�Jt�[7Lu �tiL
Addre�r �0 f'i r"7k Co�� �—
Ciry/StatdZip: � .ld �T� � � QI S7 Nhone N� 7 � � 7�U�7 7 �� �
,\re yo� a�empbyer'CAeek the ypproprlate bos' TYpe of proJect(requlre�:
I.�am a employa wi�b Z� 1. Q I�un a acncral eontraetpr aod 1 b. ❑Naw conawetioa
employees((ull and/or pan-dme).• have hired ehe mbcontracaon
2.0 1 am a sok proprietor nr panneo- lisrcd on �he anuhed eheet 7 7. � Remaklin`
.hip:ud have na cmployee 7�+e�wbconteutas haw B. ❑ Ikmolitiat
workin for me in an ca aci ��orkm'comp.inawanx
i Y P �Y• 9. � Duildins addition
�No wahers'comp. in�urance S. 0 We aro s corporstim and id 10.0 Electrical rep�in w addieioiu
rcquireJ.) ofTfcen have e�eereixd cheir
3,0 1 un a homeuwnar Join�all woh �ylu of exanprion pa MGL ���Q P��bin�tepain a rdditioro
myself.(\o worken'comp. c. 132.�{1(4).and we have no 12.�Raof rep�irs
insunnce requircd.) t �mpbyees.�No work�n'
comµ inwnnce requind.J t l.Q O�her
•nny�pplicanl�lut crtaY�Eat II muY alwr fill w1�M yuia�Eolov iAorie�tMit�rpktp'winpen�puliry infurmatlon
'I h.neu+r'en rb�ubnil tlle'ifll6vh ind{ain�ihry an Join�{all rwrk an�Mo Ilin aNride emuscbn muM iuAnil�nw a1lt�hvG indio�iq ns�k
{�.,n���o��Iu1 chaek iAu Em�mup anmld an aWi�i�wd+Aal+howin�U�roiee of�M wdeoevsfon and iAslt wuAw�'�wny.pyliry iafsmotia.
' /mw aw employtr rh�f bProvid/n�workia'roui0tnrodow lnsrnen jor ney rspluy�n, as/ow/r fhr pe!!q ow//oi y!!i
;njo.mwion. �
� Insurance Company Vame:�
� Policy N ur SelGina. Lio. p: I� � 2 3 v�7 �-✓ � Expirrlioo Date: °'C" �P�� [) .
fob Sire AdJrcu: �� d7'� �I Sl � �� Ciry/Sa�e/Zip: ��r} �P.fi✓1 ��z�-
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,�tuc�s copy of th�werYsn'comPsm�tb� pollry deelantb�pap(i�owln�th�polkry aumMr�s��:pinNo� d�b}
f'ailum ro�cure covenga y requircd unJer Sec�ioa 23A uf MGL e. 132 can lead ro th�impwition of criminal penaltie�o(a
fine up ro S I,S00.00 anJ/or one-year imprisonment,as well a�civil penrltin ia�ha lorm uf¢STOP WORK URDER and�fid
� of u f0 SISO.00 J J� a � ins� �he violamr. Ik aJvii.al ehat a a�py uf this�atement ma be fowurded to�he Olfice of
n r � r
� Inr�•�ug��iuna a(dro f71A far insurance coveroge vcntiertiun.
� � /Jo her�by enrijr m �rhi i ytnu/t/�t ojptr/u � i in�wnrarlow pravided ubov�is rrwt und tuii�K
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P�iire A� 7 0 / � 7��`i '
I O�ri�!u�e mdjt qu nat wril�in ihtit rrrr, ra d�.uirrp/a�/br riry ar ioww�i/fk'iuL � �
ICiry or fuwn: -- - -- Yrtmit/l.lccmt M--. _ --_ �
' hsuinr.\whuri�rlurcleune�: . . -� i
� I. ItwrJ of IIr�Uh t. Ruildln� D.pu�m.nl ). Cily/fown Clerk J. Eledrical In�pcaro� 5. PlumbinR In�pecior
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;�Iw�; PL•`BLlC: PROPRERTY
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('nnstrurtiun Ucbris Uisposal .-�1'lidavit
(rr��uir�� li�r aU �cnwlition :uiJ rrnw.iUun �vurA)
In acrurdanc� +��th �hr sixib rJition ul'ihc Slatc Duil�iny CoJe, 7�U CAIR xcuun I I I �
D�Uris. .mJ thc pro�'isiuns ul''�1GL c �0, S 54;
DuiWing I'ermit N is issucd �viih the conJitiun that thc dchris resul�ing from
this ��urk ih:ill br di;pouJ ut in a prop�rly IicrnscJ w�,te Jisposal I�ciliry as d�tincd by MGL c
I l I. S I SOA.
Th dcbris ��'ill bc U:msportcJ by:
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7 hc drbris ��ill br dispuscd uf'in �
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'L� 1 uainr ul Nu ny) .
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� ACORD INSUt�AIVCE BINDER SP °"�
,. RO'76 06-10-2009
�THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE S�DE OF THIS FORM.
I FRODUCER PHONE COMPANY e/NOER A
R/C No Ex�:
PAYCHEX AGENCY INC Hartford Accident & Inde 1-Z3U7WD
EFFECT/Vf EXF/RAT/ON
308 FARMINGTON AVE oa� T/ME OATf nMe
FARMINGTON CT 06032 o6/os/zoo9 12 : Ol X AM o�/05/2005 X 12:01 AM
�� _ - PM NOON
THIS BINDER IS ISSUED TO EXTEND COVEHAGE IN THE ABOVE NAMED COMPANV
COOB Z 1 O�I O S SUB CODf: PER E%PIRING POLICY ll:
AGENCY DESCMYDON OFOPfRAT/ONS/VEMCtES/PROPERTY!/nc/nC"mg Lovtian/
CUSTOMfR/O:
MSUREO
J&S CARPENTRY AND CONSTRUTION INC
22 FOREST STREET
MIDDLETON MA 01949
COVERAGES � LIMITS
TYPEOFlNSURANCF COVERAGE/FORMS OEDUCTIBLE CO/NS% AMOUM
PROPERTY CAUSE$OFLO55 .
BnSIC �eftOAO � SPEC
GENERAGG/AB/L/]Y EACHOCCURRENCE 5
COMMEFCIAL GENERAL LIABIIITV FIRE DAMAGE�Any one frel S
CLAIMS MADE �OCCUfl . MED EXP�Any ane Oerson) S
� .PEflSONAL&NDV INJURY 8
� � � GENEFAIAGGREGATE S
flEfRO DATE FOH ClAIMS MADF. PRODUCTS-COMP/OP AGG 5
� AUTOMOB/LE UAB/LRY � �
COMBINED SINGLE IIMIT 5
ANY AUTO BODILY INJURV(Per person) 5
AlL OWNED AUTOS BODILY INJI/RV(Per eccident) 5
SCHE�ULED AUTOS . - PROPERTV DAMAGE 5 �
HIREO AUTOS _ MEDICAI PAYMENTS 5
NON-OWNED AUTOS PEFSONAL INJI1flY PROT 5
UNINSUPEDMOTORIST 5
5
AUTOPHYS/CAL�AMAGE DEDIICTIBLE. ALLVEHICLES SCHE�ULEDVEHICLES ACTUALCASHVAWE
LOLLISION: STATED AMOUNT 5 � '
OTHEN THAN CO�: OTHEfl
GARAG£UAB/LRY AUTO ONLV-EA ACCIDENT 5
ANV AUTO OTHEP THAN AUTO ONLV:
- � - EACH ACQDENT 5
� � ' AGGHEGATE 5
EXCESS(/A82(TV
EACHOCWFflENCE 5
UMBRELLA FORM � AGGREGATE 5
OTHER THAN UMBRELLA FOflM REfRO DATE FOH ClAIMS MADE: SELF-INSUflED RETENTION S �
_ � . X WC STATUTORV LIMITS -
WONHER'SCOMVEMSAT/ON 76WEGLM8416 E.L.EqCHACCIDENT S1.00� 000
, EMPLOYERSL/A84?Y _ E.L DISEASE-EA EMPIOVEE SZ O O� O O O
E.L�ISEASE-POUCV LIMIT SS O O� O O O
�C�q� - FEES . 5
CONO?/ONS/ �-
OTNER TAXES 5
COVE2IG£5 -
- ESTIMATED TOTAL PREMIUM 5
NAME & ADDRESS
' � . MORTGAGEE ADOITIONAL INSURED
LOSSPAVEE ' ( '
J&S CARPENTRY AND CONSTRUTION INC LOANk
22 FOREST ST
MIDDLETON� MI� 01949 AUJNOFIZEDREPRESEMAT/VE ,
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g�ven are subject to ver�ticat�on on yj' p � not be released or copied unless Printed: 7/l4/2009 I :
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