31 IRVING ST - BUILDING INSPECTION (2) t� The Commonwealth of Nfassachusetts
1 i Board of Building Regulations and StandardsJ
�t�LE�I
1j Massachusetts State Building Code, 130 CMR
ed blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demol
One-or Two-Family Divelling
'[his SictioriFbrOtiicial usionly.
Building Permit Number: D3t _ pplied
Building 0Mcial(Print Name). Signature.: Data
SECTION l:SITE'INFO%h EATION.
1.1 Property Address: 1.2 Assessors Map Br Parcel Numbers
L 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 R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:(M.O.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 es❑
SECTIONZ;' PROPERTB'OWNERSRIP!
2. Qwnert of Record:
\.('_\<— in4 �h\GS Sg1 .1 1^\G, C3iCi�/G
Name(Print) City,State,ZIP
3 ► -1rv;+r, S�• 478- 7q,4-3S8q
No.and Strcet Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED3VORW'6heck all th4t apply)
New Construction ❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': Rev,--to C\ R011 k,C e 10 x lco eG K—
SECTION 4: ESTINLaTED CONSTRUCTION COSTS
Item Estimated Costs: Ofil!0al Usi Only-.
Labor and Materials
I. Building S '7tCG, / I. Building Permit Fee:S' Indicate how fee is determined:
2. Elcarieai ❑Standard•,City/futvrrApplication Fes
❑'rotatPitijectCOStr(Item.6)xmultiplier e
]. Plumbing S ? Other FeeB: S
t. ,MI ehanical (IIVAQ S List:
i. ,Meehanic.tl (Fir':
iu� rrc„ion) _ 1 MI All Fees:.S
Check No. -_Check Amount: __cosh :\utnunt
❑ I,
r fatal Project Cnit $ _---
f girl in Full 0 Outst:uidim, Valance Uue:
SECTION 5: CONs'fRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL 1 folder List CSL'rype(see below)
�a [CG. ('fiti" S Type Description
No. and Street Unrestricwd Duildin s u to]5,000 cu. tt.
Spt\e„^ I^1c\ C) kcl-7c) R Restricted1&2Famil Uwellin
Citylrovvn,State, GIP ivl �'LooTi
RC Rootin Coveririg
WS - Window and 5idin
SF Solid Fuel Burning Appliances
00 Ska -CfOLf f Insulation
rcle hune Email address U Demolition
5.2 Registered Home Improvement Contractor(l1[C) IS a,e-f 6 7�4 �
C G C q\ C r I, • ^Cj HIC Registration Number Ex
q piration Date
I Ili mpanyCN2un 4 i�QRc3u��t Nona
1 h Email address
No.and Street o 1czi-0
City/Town,State 'LIP Pale hone
SECTION 6: WORKERS'COMPENSATION INSUlwcE 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 denial of the Issuance f the buildingpermit.
Signed Affidavit Attached? Yes .......... dK No..:........
H CON[PLETED WHEN
SECTIO Ta OWNER A E
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
(�x Cw- rv-)q q S Unte
Print Owner's Naine(Electronic Signature)
SECTION 7b: OWNER'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.
_
Print owner'i or WiiI0I14Cd:\gmtt'i Naute(Gleu Deteronic Signature)
NOTES:
I. :\n owner who obtains a building permit to do his/her own work,or an owner who liires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will Lint have access to the arbitration
program or guaranty find under MAY.L.c. 142A. Other important information on the HIC Program can be found at
wives m;tss.euv%ata Information on the Construction Supervisor License can be found at tvww mass.w,rtlL{
2. When substantial work is pianned,provide the information below:
Total floor area(sq. 11.) _____ _(including garage, finished basement/attics,decks or porch)
tirosi living area(.it(. it — tfabitable room count _
oFtirtplaecs_ _------- `lumber ofbcdrotlins
Number
Numbert) tirelrnonu _._---- Nuntherofhalhb:uhs -------...__---
— ---
I`.peofhe.Iting ;y;tent Nnmbcrofdeck..'taxiIts -. ... ---- .
f{ncloied ()Pen
�\l+e ,+ftonlin� iyatw _ ---
i
k `4
' •2 `i s. 'may+ M` r ^n<
',l } .t 1 .�, Nr.n 6 .$ xy A 'fii e.^, b '-I 5 d' 4 � b.1+t'• q'�ti'T.
CITY OF S:1I, Nf, mASSACHUSETTS
r BI:ILONG DEPAEVV IMNT'
120 WASHLNGTON STREET,3"FLOOR
TEL (978) 745 9595
RLX(978)-740-9846
�3(gFRi RY DRISCOLL
MAYOR THo&LuST.P1Ew1
DIRECTOR Of PUBLIC P,ROPEify/BCII,DING CONL11MIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors]Electricians/Plumbers
Annlicarit information -� Please Print Le ibiv
Nance(BusiiwssOrginirationAndividual): —� J� CPnP/'Lt` Cok\�rgc j, 1Q .
Address: Ca. 't
City/State/Zip: Sc (rvvl rhq aIS2a Phonell: 478'- SR-o— 9 7JL
Are yay an employer?Check the appropriate box: Type of project(required):
I. 1 am a employer wit& 4. 0 1 am a general contractor and l 6• 0 New construction
employees(fLil and/or part tithe).' have hired the subscoinractorg
2.O1amasoie'proprictorur' ral listed on thtrattachedsheet,i, 7• ❑2emcdeling
ship and have no employees These subaintraetois haves $ []Demolition
working;forme in any capacity:' workers'comp insurance. g 0 Duildmg addition
(No workers comp;,insurance. 5. 0 We are a corporation and its>
required:) otttcers have exerclsed their 10 0 Electrical repairs or additions
3.0 (am a homeowner doing all work right of exemption per MGL . ` 11.0 Piurnbing repair or additions
myselE:[Yo workers"comp. c. 152;gl(4j;and we have no'_ 12.0 Roof repairs
insurance required.)t employees;[No wotken';i t
comp intiurnncercquirrd:j .'= l3.DOtfier'
Any applicurd that chccka boa ll mats also rill uul the section bdowshowing their workem'mmpeo"don policy ttifunnotton',
I r,"euerm"who submit this affidavit indicating thry ate doing all work and thpf hlro amide cantfaaon most submit a new afRdavil indicting such.
_ !Contractor that Omit this box most attached onikti adur ul sheet showing the name of the sub-contruYoo roil ihob;woron,,cwnp paltry infamutaa..
fain art employer that is provlding lsorkers'cotnprnratlon lnstircnce +ny empluyerx 13eluw!s the policy undJob site
informutlan.
Insurance CompanyName: �OS-e .}►y "t7�S—I ^ �o�(pl�
Policy Al or Self-ins:Lic.0: Expiration Date• '
Job Site Address: I ..Trysr\ .
City/Stattr/Zip:_�S tPr•1 r"�G
Attach a copy:of the workers'compensation polley declarotlan.page(showing the Policy rumbas and expiration date).
Fai(ura to.seIcure coverage as required under Section:25A of MGL e.152 can lead to the imposition ofcriminalpenalties of a
tine up to S 1,500.00 and/or one-year imprisonment,all well as civil penalties in the form of a STOP'WORK ORDER and a fine
of up to$250.00 a Jay against the violator: Be advised that a copy of this statement may lxforwordpd(o the Office of
Investigations ofthe DIA for insurance covcraba ycrilit.ahurt.` ' - - -
/du/rerrby t err tiudn the pules and penuldet ojpertuo t/mr7/re lnjgr+nutlen pravidrd above is true and correct
Si m-uure
Data r' a lQq -Zoo 13
c
Ofrclat use aniy. Du not write in that areas to be completed by city of town afJ/ciat
City or'ruwn: Permitil.1cense At
Issuing Aulhority(circle one):
I. Buard of Ilealth 2.Building Department J.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.01 her
Contact Person: Phone#•
rjy ,
CITY OF S.1-LZNfj
L1L1s5:1CFi(,SETTS
1� ,{ 1'01 ASULYGTONStUST, }"FLOOR
<iS[OEUEY DRI'SCOLL FLX(979) 7•W-9344
,bUYO'Z T�tOSC�ST.P1ER1i8
DIaECTOR OF PI:OLiC PROPERTY/g�t1.04VG GOSL\(155IO.V ER
Construction Debris Disposal Aftldavit
(required eor all demalition and renovation work)
In accordance with the sixth edition of the State Building Cad, 73p Ci1lR section l l LS
Debris, and the pravistuns of tNIGL e 40, S 34;
Buildinghiw k Permit y 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 ris re ul ,LICE c
I 11, S ISOA.
1'ho debris will be transported by;
Jc�h lr DePo-�-
(namr ut'hauler)
The debris will be dispascd ot'in :
NMI,:or facility)
si•tndntre nrperntit a
PPlic.uu
�� as ao 13
I