1 LAFAYETTE PL - BUILDING INSPECTION (2) �!
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I � The Commonwealth of Massachusetts
/ I I ^� Board of Building Regulations and Standards CITY OF
/1,� /� Massachusetts State Building Code,780 CMR Revised Ma 2011
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Building Pemut Application To Cons[ruct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
T'his Sec[ion For Official Use Only
Building Permi[Number: Date Applie :
�- � � t2 9
Building Official(Print Name) igna e a[e
SECTION 1:SITE INF TION
1.1 Proper[y Address: 11 Assessors Map&Parcel Numbers
l .�K1F/�`vEtfiF. I�Gr�cls '3� b'�oo
Lla Is this an accepted sheet?yes no Map Num�- . Parcel Number
1.3 Zoning Informafion: 1.4 Property Dimensions:
�")�-1 C�
Zoning District Pmposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) -
Front Yazd Side Yards Rear Yard
Required Prwided Requ'ved . Provided Required Provided
1.6 Water Supply:(M.G.L a 4q§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public��l Private❑ Zone: _ Outside Flood Zone? . Municipal O On si[e disposal system ❑
C6eck if yes0
SECTION 2: PROPERTY OWNERSHIP�
21 Owner of Record:
r vsu ��,-, �'.eC.i�F..v�. S.ac�.-, �-, � • [�19��
Name(Print) Ciry,State,ZIP
I Gs�Gwy��F_ j>c�c�-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
� New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) �Cl Alterauon(s) ❑ Addition ❑
� Demolition � ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': , � �" L/.�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
I�� Estimated Costs: pgficial Use Only
Labor and Materials �
1.Building $ �, �0 �� 1. Buildiug Pemtit Fee:$ Indicate how fee is detemilned:
2.Electrical $
❑Standard City/Town Applica[ion Fee
❑Total Pmjec[Cost�(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechauical (HVAC) $ List
5.Mechanical (Fire $
Su ression Total All Fees:$
.� Check No. Check AmounT. Cash Amount:
6.Total Project Cost: $ ��� ❑paid in Full ❑Outstanding Balance Due: ���
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SECTION 5: CONSTRUCTION SERV[CES
5.1 Constructlon Supervisor License(CSL)
<,�G I `B 3 SG., /n -l-iz
�.[,��)-7F,n,J �VM'�/►+�ti(�S LicenseNumber ExpiretionDate
Name of CSL Holder u
^ p p\ List CSL 1�pe(see below)
y�� �l7 CGNc7•�/�s93 1.7/L r
No.and 5�eet Type Description I
1�Er��S b��y {�l� � � 9 G� Uarestric[ed uildin s u ro 35,000 cu.ft.
Reslricted 1&2 Famil Dwelliu
City/Town,State,ZIP M Maso
RC Raofin Coveri�
, WS Window and Sidin
SF Solid Fuel Burning Appliances
978�.6s'-y39.4 1 Insulation
Tele hone Email address D Demolition
51 Registered Home Iroprovement Contractor(HIC)
/? /1 /o-� /
li�� i a'�'S l.��`�T���r��%�� HIC Registration Nwnber Expiration Date
HIC Company Name or fiIC Registrant Name
�� �G?l �h✓aw.f-9S l�✓L ar.�. .+v t
N�and S�et Email a dress
I- ��3��ay �� ��9r.,� 9��a�r�39�
Ci /Town State,'ZIP Tel hone
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[he denial of the Issuance of the building permi[.
Signed Affidavit Attached? � Yes ..........�f� No...........❑
SECTION 7a:OVVNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject proper[y,hereby authorize
to act on my beha in all matters relative to work authorized by Uils building permit application.
. •`1 i
Print Owner's Name ectronic Si�ature) Date
SECTION 7b:OWNER�OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penal[ies of pe�jury that all of the information
contained in this a ication is true and accura[e to[he bes[of my knowledge and understanding.
.
Print Owner's or Authorized Agenf s Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building pemilt to do his/her owu work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Progam),will not have access to the azbilration
pmgram or guaranty fund under M.G.L.c. 142A.Other important information on the H[C Program can be found at
www.mass.eov/oca Infovnation on the Construction Supervisor License can be found at www.mass. ov� /dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemenf/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces � Number of bedrooms
. Number of bathrooms Number of half/ba[hs �
� Type of heating system Number of decks/porches
� Type of cooling system Enclosed Open
3. "Total Project Squaze Footage"may be substituted for"Total Project CosP'
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i J � CITY OF S�1LE:�1, �L'�SS.-1CHLSETTS
BtiIIDLYG DEP�R'['�(&�iT
• ' �• l?O W.�SHINGTON$TREET,3�D F1.00R
`� �'j TeL (97�745-9595
Fnx(97$)7�10-9846
�1ffiFAi Fy DRISCOLL
VL�.XOR Tt�osus ST.P�t&
DIRELTQ30F PI:HLIt PROPER3Y/BL'IIDL�1G CO�L�fISSIOtiF1t
lVu�kers' Compensation [nsurance Aftidavit: Builders/Contractors/Electricians/Plumbers
Apn�icant Information Please Prin4 Le iblv
Vame tu�sf���or�o�:�uoNi�a���a��q: l . CIMr�iw 1f�T (9 �T.�� l C� '�1C9A.�
Address: �� I�UC+4�Yo,v7x11 { /I
Ciry/State/Zip: L�Ef4/:�o��4� l+�izi Oi9�Phone k:_� 7� -.Z�-►'- 9395�
.. :�fe pn w�n�InvFr?(��nr4[ho E�RrpFria(n M�� i y�iE uP p7ujeci(requi�cdj:
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1 1.�j� 1 am a cmoloyer with 4. � 1 am a�enpal contractor and 1 u. �Ncw conYWctiun
� eniployees(fu�l au�L'oe paci-[ime).' have hiccd the subconi.acinrs
2.� I am a so�e propricror or partnory listed on the attached sheet� 7• ❑RemoJeling
>hip anJ have no empluyees These subcont[actors have S. �Demolition
working for me in any capaciry. workers'eomp.insura�e. 9. �Bailding addition
[No workers comp.insurance 5. ❑ We are a corporation and its �0.�Electrical repairs or addicions
rcquireJ.] offieers have exercised their
3.❑ I am a homeowncr doing all work ril;ht of exemption per MGL I I.Q Plumbing rcpairs or addirions
myself.[No worlcers'comp. c. 152,§1(4),and we have no �Z,0 Roof�epairs
insuranct required.J f employens.[A'o workers' �3❑��Q
comp. in�urance required.J
'Any applipm Ihat�hecke box p I mus�aiw filt uu�ihe sectim below slrowiag iAe'v workpi oomprnptiun poliry infortnatian.
�I lnmcu�vm,n who su6mit Mis aftidavn i�ieting ihey ne doing all uro�it and thm hiie outaide coNr�ctpia mWt aubmit a�rc�r affiJ,ivit indioling suth
=Camraeron�Mt check ihii Aox mut anae a vld''a ' n�M mmn f eM..� .,e� �:.....�._. .:'`_ _"'_
. . . .!!oA n_.._il�mal.Irce�shoWina..._..:.._c.....__�n:r.��..�•�,.i..,....:.e u,�-y.-y:,iiryo��w��.��w.
1 am va employer rhat&praviding workers'comQr+isauon insamnee jor my empluyees. uelow Ia fHe po!!cy ond Jab slte
injormufion.
Insurance Company Vame:
Policy N ur Self-ins.Lic.N: Expiration Dute: �
Job Sire Address: CirylState/Zip:
Attac6 a copy of lhe worken'compensadon pollcy declarotlon page(showing t6e policy oumbor and e:plroHon date� '�
F'ailure to x:cure coverage as required unJer Section 25A of MGL a �52 can lead to the imposition of criminal penaltiea of a
fine up to SI.500.00 and/or one-year imprimnmen4 os well as civil penulties in thn form of q STOP WORK ORDER and a fi¢e
ef up ro 5250.00 a Jay�gainst�he violaroc f9e aJvised[hat a cupy uf this uatemcnt may be forwarded ro the Office of �
inves�igmiva.uRhe DIA for insurence rnvcrage verificalion. I�I
l do Irereby crrdjy unQrr tkr patns arrd pertalfles ajpe�Jury tbat tGe injarinutian pruviJrJ above Js true und correct I
Si.nat�ret . � 1?aiC' —
on �:
O�cia/usc on1y. Do not wrile in dris urea,to be curupleled by city or lown nfftciuL .
City ar Tuwn: Pcrmit/I.icenye M
luuing A W hority(circle onc): �
l.livard uf Ilealth 2.Buildinb Department ].City/fown Clerk 4. Electrical Inspector 5.Plumbing Inspeeror
6.Othcr
�art�ci Pcesan: 1 hone te:
0 _ ..� .�- - - _��_. .— - � -
CITY OF S.UEN, iNLkSSACHUSETTS
BUILDING DEPARTMIUNT
• 120 WASHINGTON STREET,NO FLOOR
`
TEL. (978) 745-9595
FAx(978) 740-9846
KI.NfBERI.EY DRISCOLL
MAYOR THoarns ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUUMNG COMMISSIONER
Construction Debris Disposal Affidavit
(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 c 40, S 54;
Building Permit# 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 by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
r3i- L
(name of facility)
tiF"J3,-wV s4 PZAJ r3 y
(address of facility)
siqsUe of permit applic
to-r�-1 i
date
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