19 INTERVALE RD - BUILDING INSPECTION (2) 3�- cry 166 3
The Commonwealth of Massachusetts RECEIVE�ERV CES
? '" a Board of Building Regulations and Standards (NS ECTW1M1)
,� Massachusetts State Building Code, 780 CMR SALENI 4�
Building Permit Application To Construct, Repair, Renovate Or Demolish a
10 OCrlrz�i�
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date%oYFpiied:
Building OfFcial(Pont Name) Signature V pate-
SECTION I:SITE INFORMATION
I.I Pro ert kddress: - f 1.2 Assessors Nlap& Parcel Numbers
�O
I.I a Is this an accepted street?yes no Map Number Parcel Number
FZoni1.3
ng Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arca(sq fQ 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.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSIIIPa
2.1 O
wner'oof,R,ecor( -
Na nc(Print) City,state,LIP
Pu'�./P i� — 4- ice
No. and Strect telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ R pairs(s)>6 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $S�w, �9-- I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑$tlnldard City/Town Application Fee
❑-Total Project Costs(Item 6)x multiplier_ x
3. Plumbing $ 7. Other Fees: $
4. Mechanical (IIVAC) $ List:_
5. Mechanical (Fire
Su a)ression) $ Total All Fees: $_
Check No. Check Amount: Cash Amount
6. Total Project Cost: $ �'QOU, at) Check
Paid in Full ❑Outstanding Balance Due:
S1.T3 IONS 7 rlt• � �c7
SECTION 5: CONSTRUCTION SERVICES
e f 5.I Construction Supervisor Lice ns (CSL)
Off�. �M/V//� nens7ys— ,
{� a.(�( License Number Expi anon Uate
C , Namo of CSL Holder
h Inr List CSL'rype(see below)
No.and'suceeel Type Description
S_1 ,/0�� /��� O/ 7U , U Unrestricted Buildings u to 35,000 cu. ft.)
CY/ f r�z / R Restricted 1&2 Famil Dwelling
CitylPowq Stale,ZIP' M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
970 —777 IXJO I Insulation
Telephone Email address D I Demolition
5Megistered H�o�m'�/Improv mee�nt Contractor fU 3 O S
���l`"" t Y� S � 2/6
HK Registration Number Kxpiration
I IC CumparX Name ofIiIC Re� Name
zzlskl a
No.an r t
Email address/
.01�12o g2� 7yya3��
City/Town,State,ZIP "I'ele hone
SECTION 6:WORKERS' COrNIPENSATION INSURANCE AFFIDAVIT(NLG.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
I,as Owner of the subject property,hereby authorize �"/ /��� V .
to act on my behalf, in allmatters relative to work authorized by this building permit application.
Gli7 D / 1 o✓c� r c/a c 1
Print Owner's Name(Electr nic Signature)
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 in this application is true and accurate to the best of my knowledge and understanding.
I'�.Mr Authorized Agent's Nfime(lilectronic Signature)
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.nhass.gov/oca Information on the Construction Supervisor License can be found at www.nrtss.tov/dnS
2. When substantial work is planned,provide the information below:
"rota) floor area(sq. ft.) _(including garage, finished basement/attics, decks or porch)
Gross living area(sq. R.) Habitable room count_
Number of fireplaces___ Number of bedrooms _
Number ofbathrooms Number of half/baths"Type of heating system Number of(leeks/porches---
orches ___
Type of cooling system_ Enclosed Open__
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
CITY OF St1I.EM, A-kSSACHLSETTS
BUHDING DEPAR'r\ff-NT
120 WASHLNGTON STREET, 3AD FLOOR
TEL (978) 745-9595
F.s x(978) 740-9946
KIN(BERLEY DRISCOLL
VLAYOR THOhtAs ST.PIERM
DIRECCOR OF PUBLIC PROPERTY/BUILDD4G CONLIIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlcians/Plumbers
Applicant Information �/ _ Please Print Legibly
Name (Ousine /s(�Jrlgan iza(iom9ndividu//at): �r�r—w//-C,:A///1 a7q te,
Address: la 4//r/ NSF s y
City/State/Zip: Sc&/fW r< O 611'170 Phone #:eye 7d'-7CI'W_-�3eC2
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 urn a general contractor and 1 6. ❑New construction
r employees(full and/or part-time).• have hired(he sub-contractors
2 l am a sole proprietor or partner- listed on the attached sheet.: ?• ❑ Remodeling
.hip and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity,
workers'comp. insurance. y. Building addition
workers*worke 'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ Iran a homeowner doing all work right of exemption per MOIL I LEI Plumbing repairs or additions
myself. [No workers'cump. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. [No workers' j;.0 Other
cump.insurance required.)
-Any uppticum dur checks box BI must also fill out the section below showing their workers'compensation policy m14"atiun.
'I bATeawMrl who submit this affidnvit indicating they ate doing all work and then hire outside cammaors matt submit a new arridavil indicating such.
4\inunctors thus chcsk Ibis box most atlachal an.rddaiunal sheet showing the mane of the sub-contractor,and their workers!comp.pulley information.
l ant as eatpluyer.that Is providing workers'c•untpeatsadun insurance for my employees. Below is the policy used fob site
h1foramtion.
Insurance Company Name: ---_..-----
Policy 4 or Self-ins. Lic.6: Expiration Date:
Job Site Address: City/State/Zip:
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 I.500,00 and/or one-year imprisonment,as well as civil penalties in the form b'fa STOP WORK ORDER and a tine
of up to S'_30.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
bnrstigwiuns al'the DIA fur insurance coverage veritieatiun.
i du herebyMia
theQpains and tea J 'es of perjury Jtut the infannutlan provided above is true and correct.
Sicnartirc' /Kfr�, /iii Date,
Phone 1' �2 �'yL ya 7�
OQicial use only. Do not write in this area,to be cumpleted by city ur town o ficiaL
Citynr"I'utvnt ____.. . .__ Pcrmit/LlccnseN
Issuing Authority(circle one):
1. Board of health 2, Building Deparmtent 3.Cilytrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _Phone M:_.__--------, _�
CITY OF S:1LzNr tiL-USACHUSFTTS
1� t4 L3L=LN(; DEP-M-NONT
120 WASHLYGTON STREET, YO F'OOR
-I'tL (978) 745-9595
tUJBERI Y MUSCOLL FAX(978) 7.10-994S
A�LaYO L TrgosLA.sST.FiF_US
DIRECTOR OF PusLIc PROPEQTY/8L:UMLNG COSLI(ISSIO,iER
Construction Debris Disposal Affidavit
(required for all demolition and renovation worts)
In accordance with the sixth edition of the State Building Code, 730 CDR section 111.5
Debris, ,uhd die provisions of i'YiGL c 40, S 54;
Building Permit N is issued with the condition
that
this work shall be dis debris resulting posed of in a properly er h L c
l l t, S I SOA. P P ly licensed waste disposal facility as defined by t�1GL c
The debris will be transported by:
(n mrufhauler)
The debris will be disposed of in :
(narnc of tacdity)
/�
(atl(II'C5.5 Or t:IClhly
signature of permit applicant