43 IRVING ST - BUILDING INSPECTION (2) Zy S"- ct::�, 3
The Commonwealth of Massachusetts --SSPECFIONA SERM'
Board of Building Regulations and Standards SALEIvI
0 � Massachusetts State Building Code, 780 CMR _iUlb+��R 8 Avis IV 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Avo-Family Dwelling
:J7 This Section For Official Use Only
N Building Permit Number:' Dat pplieds
-Building 011icial(Print Name): Sip'nature Date
S i 'SITE INFORuNIATION.
n I.I Vrope //Adt�ress:' ` 3 1.2 Assessors,blap&Parcel Number
�iC.1/tI J �
J I.l a this an acce ted street?yes_ no Mop Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District r- , Proposed Use - - Lot Area(sq tt) - Frontage(11) -.
1.5 BuildingSetbacks(R)
Front Yard .' Side Yams Rear Yard-
Requimd Provided Required Provided- Required
- Provided
1.61Vnte/r gupply:(M.G.L c.40,§54) 0 Flood Zone information: 1.8 Sewage Disposal System:
Public l3 Private O. Zone: _ outside Flood Zone? Municipal O On site disposal system O
Cluck 11 esO
SECTION 2: PROPERTY OWNERSHio!`
2.1 Owneri of Record:
Wtime(Print) - City,State,ZIP -
3 y't�,f sG 1e rcr2�t-A� y7� `-1�8 6Yy6
No.and Strvel - Telephone Email Address
SECTION3:DESCRIPTIO OF PROPOSED\VORW(checkall apply)`
New Construction 0 ling Building Owner-Occupied ❑ Repairs(s) Aiteration(s) O Addition O
Demolition AccessoryBldg.e Number of Units Other 0 Specify:
Bri f Description of Proposed Work': 'r -
J�P Ls n
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Ilan Estimated Costs: Official Use Only -
Labor and Nl:tterials
I. Building s 00� I• Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
Z. Electrical s Q& O Total Project Cos
(item 6)x multiplier s
3.Plumbing s OOa 2 Pther Fees: s
a.Mcchanical (IiVAC) s List:
5.Mechanical (Fire s Total r\II Fees:s
Su ression)
�¢ Check No._Check Amount: Cash Amount:
6."total Project Cost: S oeo ❑Paid in Full ❑Outstanding Balance Due:
Matt_EED 312-2-1 � �
SECTION5: CONSTRUCPIONSERVICES
5.1 Construction Supervisor License(CSL) . —0 �• 6
'�!ro 4� L .,; ����}. LLB tcense Number Expiration Date
Name ofCSL Holder V
List CSL'rype(see below)
3d l�L 2 t S' — Typer, . Description
No.and Street
�d G U Unrestricted(Buildingsa to 35,000 cu. It.
S01"1 Alm �� / � � R Restricted 1&2 Famil Dwellin
Cityll'own,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
'I Insulation
cic hone Email address D Demolition
5.2 Registered HomelmprovementContractor(HIC) /l�3 �1b �y�2
�{1 L'i f L—L HIC Registration Number Expiration Date
I[IC Company Name o�Registrant Name yC 11144,& t J mac'.
o.,, Street O o f y2-od y(/1
Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§ 25C(6)p,
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 a building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7n:OWNER AUTHORIZATION:TO BE COMPLETED WHEN•
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Elecunnic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
hcn� ng y name below,I hereby attest under he pains and penalties of perjury that all of the information
th application is true and ace a to the best of my knowledge and understanding.
er's or Aut i cJ mt's Nante IecUonic Signature) Date
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 no have access to the arbitration
program or guaranty fund under IM.G.L.c. 142A.Other important mlonnation on the HIC-Program can be oun ar — — "
www mass.eov;oca Information on the Construction Supervisor License can be found at vvww.ntass.sov,'Jns .
t 2. When substantial work is planned,provide the information below:
rotal floor area(sq. R.) 'r (including garage,finished basement/attics,decks or porch)
Gross living area(sq. R.) 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 ofcoolingsystem Enclosed Open
3. —Total Project Square Footage may be substituted for"'rot:d Project Cost"
�. QTY OF SALSA MASSAa3USETPS
B[ 11DR4GDEPAR MWT
120 TAMC7MSV"T,3=FLOOR
TaL.(978)745-9595.
FAX(978)740-98"
%IIvJ$ERLEYDRISQ7LL -
MAYOR 7hMMSTMEM
DnmcroRcppLmucpRomm/BuoLDmccaRAMOI n
Construction Debris Disposa/Afdavit
.(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 coo,S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signatur of applicant
2z
Date
ty �
The Commonwealth of Massachusetts
Department oflndustrial Accidents
I Congress Street, Suite 100
UrPivorkers'
Boston,MA 02114-2017wwwmass.gov/dia
Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le 'bl
Name (Business/Organization/Individual):
Address: 3a +4
City/State/Zip: Sp/C0`7 PA 492fiPhone#: '?2
Are you an employer'Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).• 7. ❑New construction
2. am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t
9. ❑Demolition
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurances
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box most attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 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 MGL c. 152, §25A is a criminal violation punishable by a fine up to$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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverag verificati
I do hereb un r th ains and penalties of ury that the information provided above i true/e and correct
Silmature: ^p - Date: V.
Phone#: t O ZQ
O
fficial use only. o not write in this area,to be completed by city or town official
or Town: Permit/License#
g Authority(circle one):
ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
ct Person• Phone#•
;f
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with thew certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pemtittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NMSSAFE
Fax #617-727-7749
Revised 02-23-15 www.mass.gov/dia