31 IRVING ST - BUILDING INSPECTION The Commonwealth of Massachusclls
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR. 7ih edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 11l1Om'YIM
One- or Tiro-Fumil Duelling
This Secti or Officia Use Only
Building Permit Number: / - Dat App ed:
Signature: ✓vim IANV
Building Canun651onerl lnspectoro uddings Date
SECTIO :SITE INFORMATION
L1 Property r" : A 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted stree ?yes .i no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(It)
1.5 Building Setbacks 00
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 ster Supply:(M.G.I.c.40,154) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP' /
2.1 OwnepSof
Name(Print) Address for Service:
t�lc�flaRn lrlAT7--tfl�-S '
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Workr:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building f I. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
). Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5 Mechanical (Fire S
S� ression Total All Fees: f
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S J�o 00,0({ 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL) 2 0�6 f �� .2( o 9
L,ccroe Number Expiration Date
Nyoe of CSL-Hylder Lw CSL Type(sce below)
a T Description
Address / Q / f
la (1 U Unrestricted u to 35.000 Cu. Ft.)
R Restricted I&2 Family Dwellm
Signs re M Mason Only
r RC Residential RoofingCovering
Tetep on� wS Resdential Window and Siding
9-7 -'/VT—ss�`� SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
0affidavit
tered Home Improvement Contractor(HIC) ldGI6
ny ame or HIC R istrant ame Registration Number
f7if_7 yj^.Ssg 2 Expiration Date
Telephone
TIO 6:WO RS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.S 25C(6))
mpensation Insurance affidavit must be completed and submined with this application. Failure to provide
it will result in the denial of the Issuance of the building permit.
gnedavit Attached? Yes.......... 0 No........... 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
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.
Si nature of Owner Date -
SECTION 71b: OWNEW OR AUTHORIZED AGENT DECLARATION
I C�s df-Ez� , as Owner or Authorized Agent hereby declare
that the slatemenis and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Pr f)90 ro 0 13Efl- 1' 1?F
Print Name 7/0O/Q 9
Signature of Owner br Authorized Agent 7 Date
(Signed under the pains and penalties ofperjury)
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 ma have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, 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 halfbaths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage'-may he substituted for 'Total Project Cost"
CITY OF S.0 EM, AASSACHL;SETTS
+. Bt_'DDLNG DEPART\IE.1IT
120 WASHRNGTON STREET, )ta FLOOR
TEL (978) 74S-959S
FAx(978) 740-9846
KI,(gERIEY DRISCOLL
MAYORTHOl+NS ST.PffJuts
DIRECTOR OF PLBLIC PROPERTY/lIUMDLVG CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlclans/Plumbers
A r licant Information Please Prfnt Legibly
Naine (8u%u%:v Ortattiaation,lndivtdual):
Address: lie ��qUU 2n
City/State/Zip: /y4lao G/ 4?2 Phone N: I7e " 7i; - ,S--5—9
,%re you a■employer?Cheek the appropriate box: Type of project(required):
I.[0 1 am a employer with 4. 0 1 am a general contractor and 1 6. ❑New consumdon
employees(full and/or pan-time).' have hired the wbcauractors
2.0 I am a sole proprietor or partner- listed on the attached shceL 7. Remodeling
:hip and have no employees These sub-contractoo have V. ❑ Demolition .
Workingfor me in an capacity. workers'comp.insurance
Y P tY• 9. 0 Building addition
INo workers' comp. insurance 5. (] We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MOL 1 1.0 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' 13.0Other
comp. insurance required.]
-Any applicant that vitoct 1 Boa Of MUSS also fill call the ssxtien bSSow showing their Workers'oompanaation policy infuriation.
'I t,mwuWnas who subnN this affidavit indicating they am doing all work and then him outside eentmctota onto suhmd a naw a ldsvit indicating such.
-C.mtraa.•wm that chork this box mum adachod an additional short showing dw norms ddw suk.ayrmactom and 1he4 W eh m'ramp,policy information.
1 am an employer that b pro ildlnR workers'compenradom Inaaroaee for my employees, Belaw is the poUry mnalim slog
information.
Insurance Company Name: ,
Policy 0 or Self-ins. Lic, p: (.V C — qS, l.2 J— � �/ Expiration Date: �,).�,ZD/0
Job Sire Address: City/Slam/Zip.
,%"acb a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to 5250.00 a day against the violator. lie adviu;d that a copy,of this statement maybe rorwarded to the Office of
Invcangations ul'dte DIA for insurance coverage vchlication.
1,10 hereby errtify under the poiiins,,mood ape tulNes of per/try that the irrformarlon provided above is true and correct
�n'n'tlnre: t 9 FJ•r-Ais/,on.L. I)utC( -7
Phone A
Oflhial rat only. Do tot mire in this area, to be cminpleted by city or town,,1 leidi
City or fuwn:
i
Asuing Aulhority (circle one):
I. Ituard of 11ealth 2. Ruildlnu Department ). Citylrown Clerk 4. Electrical fnspector 5. Plumbing Dntpeefor
6. Of her
Gnuact Person: Phone d:
%- CITY OF SALLM
PUBLIC PROPRERTY
DEPARTMENT
.,.I I.. \\ r,i❑'. . '.?.;1IrV \\II \I. \I�.,\i • .I' .
III '� V1� 'I"i` • I �C 'i A V: 'ii L
Construction Debris Disposal Allidavit
(reyuiICd for all demolition wiJ renovation work)
In aceurdancc will (he sixth edition of the State Building Code, 7J0 CSIR section I 1 1.5
Debris, and the provisions of 11GL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal lacility as defined by MGL c
II1. S I5f)A.
The debris will lie tiansportcd by:
I name of hau t d -
I he debris will be disposed of in
<116OL4 C
(hlJlne ul IJcdrty)
I.Iddn,, ur lit Joy)
.ILndIUIC 'It 1) nut .y+phc Jill -
.4) f 0 9