12-14 LANGDON ST - BUILDING INSPECTION _ --- Ilse C'omnwnsvcsllh ul'�I:Isia:husctls
Board of Building Regulations and Sland;trJs Cll Y OF
1 sr "'15"rhusetts Slat¢/V Building Cute, 7Su C'NIR SALEu•:u1�M
B uilding Permit ��pplicatiun 'fo Construct. Repair, Renovate Or Demolish a /?,.I med Ih
(Ate•or ruu•Fiurulr vtreffing
This Section For O17ivial Use Onl
Building Permit Number:
PDlic nn
11uilJiny 011164(Print N;une) 3iyrtat� /_ G
Date
SECTION 1: SITE INFORA" N
LIP rty A Jre LS,6, r A SI Parcel Number
I.to Is this an acre led Slreel. r no flap Number Flared Nunthur
I,J Zoning Informations 1.4 Properly Dimenslenss
Lnniny 1)I,tricl I—Impo UwllUw •—' Lot Arru(s Itl 4 Fronluyu(Iq
1.5 Building Setbacks(It)
Front Yard Site Yards Reyuircd I'ruvidcd Roar Yard
Required Provided Required Roar
1.6 WAter Supply:(M.G.I.c. 40.§Sy) 1.7 Flood Zone Informations
Ihsbllc❑ Privatr❑
Zone: _ Outside Flood Lune? Ltl Sewage Disposal System-
zone:
Ir es❑ Municipal❑ On site disposal s)strm ❑
di SECTION1, PROPERTY OWNERSHIP'
2.1 Owners of Reeor
(uy,Mule.l.IY i No.and Street I_ - '?I- 4
rwephune Einuii AJdrcss
SECTION it DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner•Oceupied ❑ Repairsls) M" Alteratlonlfl ❑ Addition ❑
Detnulilion ❑ .accessory Bldg, (3 Number of Units_ Other ❑ .Spccity:
Brief Description of Proposed Work : wtUc; iST NG —y rc t
12
SECTION 4: ESTINIA I ED COYSTRUCTION COSTS
Rent Estill wed Costs:
Il., or and.\Materials) Ofllclul Use Only
I Building S jo7 <'�'Zi`i' I. Bulling Permit Fee: S Indtcate how tee is JeterntineJ:
]. I:'lecirwal S ❑Standard Cily.Tuwn Appl(calion Fee
t I'Imuh;ng S ❑Total Project('ost'I Item 6)1 imdtiplier —__ x
I. Usher Fees;
J. \M"11,mic.d ill\ W) S List: _
\Ieeh.mic.tl tFrre _— -- -- -- .
�u�vcsiani S rota \Il Fees: S_ .. .._ .. -. ._
n I'utal Project Cn,L i%� i Check Vu. _. _ _( heck .\mtnun: . _.l',i,h \nenu If:
0 P.id in Full I]OuIS1410115 Nal.mce Uuc:
SF("I'Il)Nt; ('()Ntil'Rt1("rlt)NtiFRVI('FS
5.1 Construction Super isur License(Ctil.) Ir„iraliau Ilalc
ieen,e Nuulher I
\,uue�ll'CSLIIuLIer IIitCSl. l)tic l,eehelual.._._ .
ItPe Ilcseripliun
Nu. .mJ Street I hlreilrieleJ l lluddin Ili to 11,U0q at 11.)
v A. G/j L/-� _ It Iic,incleJ I,'l'?P.unil I)ucllin
fu„n, µC' K„ulio Cusarin
SF .tiuliJ I:uul Ilurniny \ppilull••es
I Insulution
W-01 31 - �) 5 U Dumolitiun
—•----- — email uJJresi
I'elc hone (U .j,27v '-7 ,
.,I Registered Ilome Improvement Cuutnutor(HIC IIIC' ilgisiZ ratiun NO"'h`r EsPuatiun Dote
G>GZtS�L'`'' �t-�'2r.enEL.r✓L
I I C,ompll' �,/IIIC Itegi,J I�Nanw
S�ptr�n limuit uJJnss
Nya�" 7y.6�C e`.l-iGr+eh AX
✓(.4� T¢W honer
Ci /Town,State ZIP
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e,--- ! 23C(
with this application. Failure to provide
Worker Compensation Insurance affidavit must be completed and submitted
bmit ed
this affidavit will result in the denial of the Issuan or the building p
ermt-
Signed Affidavit Attached? Yes ..........
SECTION 7a: OWNER AUTHORIZATION TO BE C0111PLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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-
Print U,sncr'1 Nwne(Electronic Signuture)
SECTION 7b:OWNEW OR AUTFIORIZED AGENT DECLARATION
By entering Iny nalne 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 or my knowledge and,understanding.
I'rimq„ncr rsNanwlClecuunt�Slgnauuul
v0'rESt
hiresan unregistered
contractor
an l
.\nOmobtain$ Other inipurtant have to the arbiritiun
jut registered i e IpruementCumrctor lHlCl r,gr
pmg`ans or guarnn'yll fodn curs on the Construction Supervisor Li enw.an be found aton the C Prugrant'c>n`bel'fiwnJ at
\\hen substantial Iwrk is planneJ, pros ide the information below:
I including garage, finished basement attics, Jerks or perdu
rotat flour err¢,1 ay. 11.) - --- Habitable room count .. -. ..
(lroiiloing ,lrealiy. it.I .. Ntimbero(hedroonls -
\umberoffireplaas .. .. _ \luubcrofhalfhathi
\unlherol'hativowms . . - ♦unlherol'Jacks. pordwi
I ,pc ot'he.11ing i),tcl❑ 01'en
Irndo,cJ
r�pc ,�l oral nlg ,�item
I
t .,r,�ldl I'r�llecl 1,III;IfI' l',h,lage IIL11 he ,IIh,11111tCd t11r..I',nal 'rojecl 0"t'.
L
CITY OF S.7LL'NI, A1SS.ACHUSET7S
Buri.Dvgr;DEPARTMENT
A 120 WASHINGTON STREET, 3° FLOOR
TEL (978) 745-9595
F.ix(978) 740-9846
KI\fBERIEY DRISCOLL
IrLiYOR T uoMrs ST.PiERRs
DIRECTOR OF PLBLIC PROPERTY/BUILDNG 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 it 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
di this work shall be sposed of in a properly licensed waste disposal facility as defined by MGL c
I It, S 150A.
The debris will be transported by:
z�-'e- Z :,:,�),JO<s/'V Z
(name o0auler)
The debris will be disposed of in
(name o 'facility) — - -
of facility)
fi5 re of permit ap t
date
CITY OF SiU EM, .NL WSACHUSETTS
r
BUILDING D EP iRV�IEINT
3 ' 120 WASHINGTON STREET, 31p FLOOR
e TEL (978) 745-9595
FAX(978) 740-9846
KIMB Ri EY ORISCOLL
MAYOR THows ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CONINIISSIONER
Workers' Cmnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A i ilicant information Please Print Le ibt
Name lBusinc�OrganizatiaNtndividual)' 2��f/6s✓ ��KGi��ZiHIL
Address: c JT
City/State/Zip: k4 k1--- Phone H:
7'
Are an employer?Check the appropriate box: FONew
ect(required):
I. I am a cmploycr with 1 _ 4• ❑ I am a general contractor and Ionstruction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. eling
ship and have no employees These sub-contractors have itionworking for me in any capacity. workers'comp. insurance. g addition
[No workcrs'comp, insurance 5. ❑ We are a corporation and irequired.] officers have exercised their al repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself. [No workers'comp. C. 152, §1(4),and we have no 12,❑ Roof repairs
insurance required.)t employees.[No workers' 13.❑Other
cutup.insurance rcquircd.j
•Any applicant that checks box sl most also fill out the ucti°n bdowshowina their worked compensation polity intbnnadon.
I Leneowacrs-he submit this affidavit indicating they are doing all work and then hire Outside contractors most submit a new anldavit indicting such.
:C,tmmotun that chak this box most attached an addhiorott cheer showing the namo of the subcontraraors and their workers'wrap,policy infemution.
lam un employer that is providing workers'c ompensadan insurunce for my employees Below Is the policy and Jab site
information.
Insurance Company Name:
Policy 4 or Self-ins. Lic.it: Expiration Date:
Job Site Address: �:� �y �'�'���"�c! '� City/State/Zip: �;>�'Gz' 04�0'
Attach a copy of the workers' compensation policy declaration page(showing the policy umber and expiration data).
Failure to secure coverage as required under Suction 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 imprisonmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to$2S0.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
1 r/a hereby certify rider set-pains- p�ena/tles ufperjury Ihar flit h formallon provided above is true and correrL
Si,"n"uurc' �"/rs ! _��.�- Data• i —��%�
Phoned•
UJficial use ally. Do nor twite in Nils urea,to be completed by city or town nfflduL
[
Citynr'1'uwn: Permit/1.1censeq
I
Issuing Aulhority(circle one): --
1. Board of Health 2.Building Department I.City(rown Clerk 4. Electrical laspector 5. Plumbing Inspector
6.Other _...
Contact Person: Phone th
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