315 JEFFERSON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of BuildingRegulations and Standards C
g tons t i lords
li( Massachusetts State Building Code, 730 CVIR bra EN
Revised Llty 01!
Building Permit Application To Construct, Repair, Renovate D�t , lish a
One-or Tivo-Family Dwelling
'Iliis SactionFbrOfficial UseOni
Building Permit Number: Date Applie
Building Official(Print Na me) signature.: Date
SECTION 1:SITE INFOMMATION
1.1 Property Address: hl Assessors Map&Parcel Numbers
315 Z je n_-,CA^
I.I a Is this an accepted street?yes no Ntap Number Parcel Number
iJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(it)
1.5 Building Setbacks(ft)
- Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:(b1.01 c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check iP es❑ Municipal❑ On site disposal system ❑
SEGI[ONZ:; PROPERTB'Oy9NERSRIP.! '.
Owner'of Record:
Name(Print) City,State,ZIP
315 T<::r F£2sc yy - Aye-,
No,and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED.WORIC''(check all that apply}
New Construction❑ Existing Building - -Owner-Occupied e(I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed 1Vorkrt
SECTION 4: ESTINUTED COtISTRUCTION COSTS-
ftem Estimated Costs: Off[clal Use Only>.•
Labor and Materials
1. Building 5 I. Building Permit Fee:3' Indicate how fee is determined:
�. Glecniatl 5 ❑Standard,City/town-Application Fee.
❑Totai Project Cost(Item 6)x multiplier x
J. Plumbing 5 ?. Other Fees 6
LMechanical (IIVAQ $ List:
. ,Mechanic.il (Piro
ink ,ressiun) _ 5A -Total :111 Fees: S_
�� ChuckAnw No. Check unt: __Cash :\u r.ioun
Ilrtal I'rnjcct ('uir $ �j y��'
_ f Ll I .lid in Pall 0 Outstandim„ I l;danca Uuo:
r
SECTION 5: CONS'I-RUCTION SERVICES
5A Construction Supervisur License(CSL)
License Number Gepirpi'rati�i U;t�te
NameufC�SL{�Iluldet ^b / List CSLType(see below)
_
I� 7 ry a Deseiptiun
No. and St tt 0-`/) U Unrestricted DuilJin s u to 33,000 cu. 11.
/ r- I A I w K Restricted Ia-, F;unil Dwcllin
City/gown,State,ZIP VI Masonr
RC Ruutin C n ndSi
\VS WindownnJSi<lin
„ SF SolidFuel Booing a\pplianc¢s
Insulation
I Insulation
'ele hung Email address U Demolition
5.2 Registered Hotne Improvement Contractor(111C) S Y
1lIC Registration Number Erpiratian Uate
I IIC Cron any Name ur II C Registrnt Natne
Email address
No.and t
Ci /Town State ZIP
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.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 ..........❑ 1 .No.... ❑
SECTION 7a: OWNER AUTHORIZATION TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR HU1LD[NG PERMIT
1, as Owner of the subject property,hereby authorize ���(� ��k rjA, MAID C C�l�c
to act on my behalf, in all matters relative to w a horized by this building permit application.
tint Owner's N�una(E atronic Sign
ature) \
Date
SECTION : NE OR AU ORIZED 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.
_ Data
Print Owners or Autlturitcd:\gent's Noma(Electronic Signaturo)
NOTES:
I. :1n Owner who obtains a building permit to do hisiher uwn work,or an owner who hires an unregistered contractor
(nut registered in the House Improvement Contractor(HIC) Program),will Pro have access to the arbitration
program or guaranty Itutd under M.G.L. c. 142A. Other important information on the HIC Program can be found at
w ww nru+.auv,'aca Information on the Construction Supervisor I.iecnse can be found at w+vw.mas to ti%:AIL
2 1Vhan substantial work is planned,provide tho information below:
Tutal fluor area(ml. 11.) —(including garage, tinislted basementlattics,decks or porch)
t rts; living:nca(;y. tt.l _— 1labimbloruwncount
lace; _ Number of bedrooms - ---------_---__-_--
Nuntleroftir�p —
Nuntherutbathmums - _-_---- .-- NumbcrofhalG'baths -.___---
f.pco(haating ;y;ttut \wither ofdxk3' l,0rclte.
n--- . _-- --__--
Euclased pen
:. 'kq.il I'nq:rt iqpi u�
" CITY OF S u_E%12 NV'L_kSSACHUSE7rS
BUILD .NG DEPARTMENT
• !?. 120 WASHINGTON STREET,3w FLOOR
TEL (979)745-9595.
Etc(978) 740-9846
NtgFRi F.Y DRISCOLI THOMASST.P1ERR&
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BU)I DING CO%WISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information P
le
ase Print LeRih1Y
Value(poolx53:Urganizatian/lndividlual): �'7�'U ��-���� �� / f (,"f��� -
Address:J``C) 1.//U/uE
City/State/Zip: �GITU�i U1���/i Phone M: -5D 9 1- / WT YT_'.
Are you an employer?Check the appropriate box: 'type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6
era yees(fulland/orpart-time).
+ have hind the sub-contractors Now construction
2. am a sole proprietor or partner- listed on the attached sheet,t 7. ❑.Remodeling
ship and have no employees These sub-contractors have a. (] Demolition
working,for me in any capacity. workers'comp.insulate. 9. ❑ Building addition
[No workers'comp.insurance 5. ❑ We.area corporation and its.
required.)-
officers have exercised then I0.❑Electrical repairs or additions
3.❑.f am a homeowner doing all work right of exemption per MGL 1 t.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,Q 1(41,and we have no 12,OA60f repairs
insurance required.)t employees.[No workers'. 13.❑Other
comp;insurance required,)
'Any applicum dhat chocks box ill must also fill out the section below showing their workew compensation policy intlusstatlon.
!I kmeowpas who submit this affidavit indicating they are doing all work and then hire oulsida ontmcton must submit a new aindmit indicating such.
:Cnntmotors that chuck this box most attached an additional chat showing IN name of the sub-cvntrutora and]holr workers'ramp.put icy information.
l am an employer that Is providing workers'compensation insurance for my emp/ayees. Below Is rile policy and Job site
iajorrnutfon
Insurance Company Name:
Policy 4 or Self-ins..Lic.H: Expiration Date: y, '
Job Site Address:;G � ` t ) ����-� woe City/Slate/Zip.J Al/&v1 *%a 0��
Attack a copy of the workers'compensation policy declaration page-(showing the policy number and expiration bate).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 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 S230.00 a day against the violator. Be advised that a copy of this statement may ba forwarded to the Off ice of
investigations ufthe DIA f 'ns ante coverage verification
I do hereby cerrijy tdh las and penalties of perjury that the iirjorma/lon provided above iss�truue and correct
Date: - V 'O✓u
Phan a•
OJJicial use only. Do not write in this area,to be completed by city or town oJpelut
City or Town: Permit/I.Icense#
Nsuing Authority(circle one): - ---
1. Board of Ileaith 2. Building Department 3.Cityfrown Clerk 4. Electrical Inppector 5. Plumbing Inspector
6.Odder,
Contact Person: Phone#:
y
CITY OFS.IL.E,tif, >bL1ss:1CHUSETTS
�\ ) QtaLDL`(G OEP.iRTNONT
120 1'V.19t4L4GTO,V STItE&T 3 Racit
:<(St0E2LEY ORISCOLL F%.%(973) 7.14-934,S
AMA 111OS&USr.PIE"A
ORECTOR OF pCOLtC pROpgg7Y/80tLOC4G COSL1(155lONER
Construction Debris Disposal Aff7davit
(required for all dcrnalition and renovation work)
In accardanca with the sixdt edition of I"a State Building Cade, 730 CL%fR section 111.3
Debris, and the provisions of MGL a 40, S id;
Building permit f# is this wu issued w resu
with tha condition that tha debris ltinI shall bo disposed of in a property licensed wastd disposal rao ttt, s lsna. ility as dJ g rrom
I}ned by �LfGL a
1'hc debris will be transported by:
�(q knL�>
The(lubris will be disposed of in :
_ l C"0 _
(name nr Cacdily)
i
ion ���Q ��
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bi{ 1»rc �tpen»it.i ptiraot
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