27 HORTON ST - BUILDING INSPECTION (2) I
ILI The Commonwealth of Massachusetts
1/� Board of Building Regulations and Standards CITY
WMassachusetts State Building Code, 780 CMR, 7`'edition ReOv S January
Building Permit Application To Construct, Repair, Renovate Or Demolish a t, 2008
One-or Two-Family Dwelling
Th Section For Offi ial Use Only.M .I'—
Building Permit Number;,' . I TDr`. . Dot Applied: i.: ie'T Trio
rt
Signature r ,. '' t 4t C�l :s P.
i '_,'Building Com m missner!inspect i m Date=
1: SITE INFORMATION -''.
1.1 Properv-Vres / 1.2 Assessors Map&Parcel Numbers
n 2
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(ft)
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❑
„." „... _r P=/fPSPC�l,4�2•e^� t`} "€EN. SECTION 2:.PROPERTYOWNERSHIP,
2.1 O tnercfye ay: . . ...d..
`J Name(Print //� Addreessscfoorr Service:
Signature Telephone
gn' A,r SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) .,,:,m € . . E C
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWorkZ: �L
L SECTION 4.ESTIMATED CONSTRUCTION COSTS '?„', , t,t "q'
Estimated Costs:
Item Official Use Only
Labor and Materials :, -
1.Building $ 1 _Bui]dmgpermitFee $ Indicate how fee isdetermined:_
s
2.Electrical $ oo ❑Standard CitylTown Application Fee
❑Total Project Costs(Item 6)x multiplier x
3.Plumbing 2 Other Fees $ •�.»:t "
4. Mechanical (HVAC) $ List.
5.Mechanical (Fire G y L
$ Total All Fees
Suppression)
CheekNo. Check Amount. Cash Amount.
6. Total Project Cost: p�Paid in Full �,. ❑OutstandingBalance Due:
( 1
,.SECTION 5:. CONSTRUCTIONfSERVICESr - I
t
5.1 Li [sed Constructi Supervisor(CSL) /7 'lD a2 l
�,C License Number Expva on ate
Name of CSL-tloldpr ist CSL Type(see below)
s V
Adds..T e t s:, ,ter. ta,3i;' 'F Desch roan ..
Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Sign at e _ M MasonryOnly
RC Residential Roofing Covering
Tele one WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation -
D Residential Demolition
5.2 Regist red Home I proC. v �ment�ntrac r(H1C)
HIC Co m any N�HIC Registr t iam ��� Registra"Dat
Ad s_--"- 0
`P7$'-5- (�(�U Expir
Sign tore Telephone
r
T SECTION 6 WORKERS',COMPENSATION INSURANCE'AFFIDAVIT(M G I c 152 § 5C(6)) r} " '
n_ss. _w _ m.._,. .
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 ..........lh" No...........❑
SECTION 7a:OWNER AUTHORIZATION,TO BE COMPLETED WHEN - 1 t x
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT-mom . .t
S
�. I, rG�/1LL✓GV i c I t�S m�� as Owner of the subject property hereby
authorize A4 //- 4Li P- to act on my behalf,in. ail matters
relative to work authorized by this bui ing permit application.
!3i—gnature of Owner el Date
' n, ,..'. SECTION7b:'OWNER'ORAUTHORIZEDAGENTDECLARATION
I, � 4 as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of er or Authorized Agent Date
Si ned and the pains and penalties of e .
,.,.,4 ... , 'd .mot rx _ s'a xNOTES. . �; s F ._I..� vim._. t. R-... o_ p� _�g ..,
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 MC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 11o.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
r 1
i CITY OF SM EN4 4 NWSACHUSEM
BLa.DLNG DEPARTMENT
120 W ASHINGTON STREET, Sae FLOOR
TEL (978)745-9595
FAX(978) 740.9846
iCI\tBERLEY DRISCOLL
MAYOR T HOMAS ST.PIERRB
DIRECTOR OF PtBLIC PROPERTY/BI:II.DING CO%L%aSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 1 Please Print Legibly
r
Name(Businax Organizzaatt'iond"dividua e
Address: 1 X 0,
City/State/Zip: to Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with_�t 4. El am a general contractor and 1
• have hired the subcontractors 6. ❑New construction
employees(full tmd/or pact-tutu). 7. Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t ❑ g
ship and have no employees These sub-contractors have If. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9• ❑ 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 I L0 Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp. insurance required.]
Any applicant that checks boa#1 most also fill out the section below stowing their workers'compensation policy information,
t f lomeowners who submit this affidavit indicating they am doing all work and then hits outside contractors most submit a taw affidavit indicating suck
'Caan ctors that check this box must attached an additional shod showing the name of do sob.comrsctors sad their workers'comp,policy inkmoUom.
I am an employer that Is providing"rkers' orapensation insurance for my employees. Below Is the pulley and fob site
information. C _
insurance Company Name: //�
Policy#or Self-ins.L2ic.#: W C.Y r� ,2 'y/ Expiation Date: /�.�
Job Sire Address: U 7 / VT/Lf�PI Gl - City/State/Zip: zj v V�` v
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 to the imposition of criminal penalties of a
fine 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 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.
I do hereby cord a pains and en tl .perJary that the information provided above/'s t eea�n/dc�orrect
. i n t tr q Date: �l O'l7"W
Phone# Tl 1
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermittUcense#
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*
CITY OF S. .E,N1, tiI.kSSACHUSETTS
' BUILDING DEPARTMENT
130 WASHLNGTON STREET,3'FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINiBERLEY DRISCOLL
MAYOR THoaL\s ST.PrERRE
DIRECTOR OF PUBLIC PROPERTY/BUMMING CONDIISSIONER
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
111, S 150A.
The debris will be transported by:
C�Z"(t ,�
(name of hauler)
The debris /will be disposed of in J
(name of facility)
�
address of facility)
signature of perm applicant
da e
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