63 1-2 JEFFERSON AVE - BUILDING INSPECTION The Commonwealth of Massachusctls Town of
Board of Building Regulations and Standards
.Massachusetts State Budding Code. 780 CMR. 7'"editwn Bwkh
g Dept
MEMO
Budding Permit Apphcalion Construct. Repair. Renovate Or Demolish a ommomwom
\ On or uv-Family Duelling
This coon For Official Use Only
Building Permit Number se Applied:
Signature: id
Budding Co s / sped of B n Date
EC T N 1: SITE INFORMATION
I.I Pro trey Address: 1.2 Assessors Map 6 Parcel Numbers
1.1 a Is this an acce led street?yes 5,/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposal Use Lot Area(Sit A) Frontage(it)
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.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site di sal s stem O
Public O Private O Check if esCl P s� Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ltitif� DUfJnJA 1
Name(Print) Address far Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O 1 Repoirs(s) t] 1 Alteration(s) O 1 Addition O
Demolition O Accessory Bldg.O Number of Units_ I Other M Specify: c,
Brief Description of Proposed Works: 5e,> u" L02 E-r2 Y uIOLL FfoLI vAV
fo%a 2e=rsove� /0�3(
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offle)al Use Only
Labor and Materials
1. Building f I. Building Permit Fee: f indicate how fee is determined:
O Standard City/Town Application Fee
2 Eleclncal f O Total Project Coss'(item 6)x multiplier x
J Plumbing f 2. Other Fees. f
a. Mechanical (HVAC) S List:
S Mechanical (Fire f Total All Fees: S
Surinression
s Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S (00 U 13 Paid in Full 0 Outslandmg Balance Due:
! IS
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supers isor(CSL)
..
License Number -Dale
N.yoe ul CSL older Lnt CSL Type(,cc below)
Tvoc Description
AJJmss U Unrestricted(up to 35.000 Cu. Ft.
R Restricted IA2 Family D%ellm
Signature M Masonry Only
RC Residential RootingCovering
Telephone w5 Restdennal Window and Siding
SF I Residential Solid Fuel Burning Appliarier Installation
D Residential Derralition
5.2 Registered Home Improvement Contractor(HIC) \
AoOCX TZr1 n-{- 077 �TA tiL<`S �7A2 UI'Y )
HIC Company Name or HIC Registrant Name Registration Number
7 COTcY/ r••' gti �U+WOND6w ti.y tik
Address
663 Expiration Date
Signs Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. e. 132.1 2SC(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 AMdavit 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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 Owner or Authorized Agent Due
i;Siancd 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 rW have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS.respectively.
2 When substantial work is planned, provide the information below:
Total Goon 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
N.
umber of bathrooms Number of half.baths
Type of heating system \lumber of decks/ porches
Typeuf cooling system Enclosed Open
1 'Total Project Square Footage' may he suh,tituted for 'Total Project Cost"
CITY OF S.UX.%1, ,NLNSSACHGSETTS
BI:aDING DEPARTMENT
120 WASHINGTON STREET, Sao FLOOR
TM (971) 74S-9595
FAx(978) 740.9&M
KI\IBERIEY DRISCOLL THomu ST.Ftmin
MAYOl<
DIRECTOR OF PCBLIC PROPERTY/BCQ1)12NIG CObMrtSSiONER
Workers' Compensation Insurance AMclavit: guilders/Contractors/Electricians/Plumbers
4oplic2nt Information Please Print Legibly
Naine (Bu%1,ea.Orgattumiorvinthva4S:d): ApCk Ter T 2E1aoI-
Address: 7 corevt"J 40
Cily/State/Zip: ^44 0305at phone* 603- 682- YSeoS
,%re you an employer'Cheek the appropriate box. Type of project(required):
1.0 I am a employer with 4. 0 1 am a general contractor and 1 6. ❑New c mstrucrioo
employees(full and/or part-time).* have hired the subcontractors
2.q 1 am a sole proprietor or partner- listed on the attwAcd sheer. : 7. 0 Remodeling
ship and have no employee Theo subcontractors have B. ❑Demolition
working for mein any capacity. workers'comp.imisrsace, 9. 0 Building addition
(No workers'comp. insurance 5. 0 We am a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.q 1(4).and we have no 12.0 Roof repairs
insurance required.) t employes.[No workers' 13.E Ocher TC^
comp. insurance required.)
•Ant applicant that checb bat et mtW atwr fill test tlw Meant Wave Showing their work='ceanpmok.Policy Wurawation.
'I hvrwwwrewe who submit Ohio affidavit indicting they are doing all weak and then him onside camnacaws mum ruhmk a new airldwa indbaaitq Slid►
=r.eurecyon thel cheek this It=mot admitted an addtiond'heat showing the retain of the qd-cymaaalan and ilia*worker'remit,pdiry iarome a .
I ales an employer that br providing,workers'compensation lnsuranea jar my employees, Slow ltr ike psaey and/ob silo
information.
Insurance Company Name:
Policy M or Self-ins. Lio.p: Expiration Date:
,?h .oft
Job Site Address: /66� St_FFCkTo,J %. &—ttZ '9&y Ott_) Cily/StatelZip: 57;�,4c�j 4,1
,%teach a copy of the workers'compensation policy declaration pan(showing ilia policy number and expiration date)6
Failure to secure coverage a 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 wall as civil pcnallie in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Ile advisul that a copy of this statement may be forwarded to the Office of
Incnugatiunt ol'dte DIA for insurance coverage venticatima. '
l do hereby Certify under rho patina and pen"/der ofern/ury that the information provided above is true and canto.
,;n_naturc: �� I)ale: /d, 7�
Ofl'ial ase only. Oa not write in this area,to be.anrplelyd by city or town,./Jia•iol
I
City or ruwn: -_ eermit/LlcenteN__.
i
hsuing.\uthurily lcircle one): — -
I. Iluard of Ilrallh 2. Building Department J.City/rown Clerk 4. Flectrical Inspector 5. Plumbing Inspector
6. th her _
Contact Person: