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3 LARCH AVE - BUILDING INSPECTION (2) ` The Commonwealth of Massachusetts CITY OF \ — Board of Building Regulations and Standards SA EM Massachusetts State Building Code, 780 CMR Revised Mar 2011 \ Building Permit Application To Construct, Repair, Renovate Or Demolish a \ One- or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Za Building Official(Print Nance , Signatun: Date SECTION 1: SITE INFORMATION 1.1_Properly�dd j s: n� 1.2 Assessors Map&Parcel Numbers c / tlf 1.1 a Is this an accepted street?yes—,?(— no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private-❑ Zone: _ Outside Flood Zone? Municipal)l On site disposal system ❑ Check if yes❑ SEC11ON 2: PROPERTY OWNERSHIP' qwnerl of 2 I A VX eLA Recorr�. ( 2�0A2'D[1S i S�L.C—M F MA 62 1Q70 Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORJO(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied 0 Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_J Other ❑ Specify: Brief Description of Proposed Work 2: w r r l 4Oe- SECTION 4:FATIMS TED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical g 1 y_ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $3 j�., 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ U �'d�. ❑Paid in Full ❑ Outstanding Balance Due: e SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) — ' G's- ol3oB3 �"io 3oly t (�)k 012 ice,( License Number E-xrptratifin Date Name of CSL Holder /O (0 -D e�8 ogLf S J List CSL Type(see below) No.and Street r Type Description © 1 0 U Unrestricted(Buildings u to 35,000 cu.ft. J R Restricted 1&2 Familv Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding /� -741 SF Solid Fuel Burning Appliances ��/ 9 VY. O ` rit U,S I Insulation Tel hone Email fiddress D Demolition 5.2 Registered Home Improvement Contractor(HIC) /U 6 0 Dl�G�3 HC Registration Number xpuaon D ! HIC Comepr Name or HIC Registrant Name 6& [ )c=�do 57 5'u:-rlr :�rU� �n".�c, No.and Street mail address /M 4 42iqW y 7f3 7Yi l yr99 Cityfrown, tate,ZIP Telephone 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 .......... V- No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner o the subject property, by authorize ^P� _I"E7'L.iZ � ��l�/ to act on b half,in all matters la' e to work utho 'zed by this building permit application. Print er's Name(Elec is ' aturc) Dale SECTION 7b: OWNER' OR AUTHORIZED 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 understandiingg..��A Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 not have access to the arbitration program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at vnvw.mass. ovQ /oca Information on the Construction Supervisor License can be found at wy w.mass.eov/d s 2. When substantial work is planned,provide the information below: Total floor 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 Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF S.U.EN , NL-kSSACHLSETTS BUILDING DEPAMIH.NT 120 WASHLNGTON STREET, r FLOOR \ TEL (978) 745-9595 FA-Y(978) 740-9846 KINfBF_RIEY DRISCOLL MAYOR T HOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG COMUSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Businessorganizatiomindividual) 13E'yt/ Jyi(?Lt tSK1b l('Lt U�L�D .5 1-.(,),.$ Address: �nli7 1 1154,CA61 r✓t City/State/Zip: S,aa_ GPtit Phone #: -/ .�B 7�{/•/4499 Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 1 am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction employees(full and/or pan-time).• have hired the sub-contractors 2_(� 1 am a sole proprietor or partner- listed on the attached sheet.: 7• El Remodeling ship and have no employees These sub-contractors have S. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. El Building addition [No workers'comp. insurance S. 0 We are a corporation and its !0.❑ Electrical repairs or additions required.] officers have exercised thew 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,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' I3.❑Other comp. insurance required.] Any applicant that Chucks box#1 must also fill not the section below showing their workers'compensation policy information. t 1 hmaowners who submit this affidavit indicating they are doing all work and their hire outside contractors most submit a r ew,alruiavit indicating suelu k7ontracmn that check This box must anacl W an additional sheet showing the name of the sub-contractor and their workars'comp.policy information. I rust an employer that is providing workers'compensation insurance for my earpiuyees. Below Is rke policy and fob 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be,forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer//11yj7,WJ�11 der rite painssaand penalties o f perfury that the information provided above is true and correct to ue; ram' C/!/ L--� Date: Phone Ofricidd use only. Do not write in this area,to be cumpleted by city or town offciaL City or Town: _.___ Permitil.icense# Issuing Authority(circle one): —_-_- - -v� 1. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing inspector 6.Other Contact Person: .___.__._ Phone M ,< CITY OF S.UE,%1, .NL L-kSSACHL'SETTS Bl:1LDNG DEPART I&NT • 130 WASHNGTON STREET,3" FLOOR TEL. (978) 745-9595 FAX(978) 740-9W 1U\IBERLEY DRISCOLL %VIAYOR THomAs ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%MSSIONER 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 transportcd by: G4 ssc (name of hauler) The debris will be disposed of in : (name of facility) = /DC/>z641tbo (address of facility) T y ,7� signature of permit applicant 7 - / 9• -�7o/j date •lcbriulydce > > � ��� �� '�^�s 'a�� �ratk/'1 � � e�iZ J - I a � 41� � � I IJ c� m New 'pr4-•t b� t rbu,�last t�cbu( o;c��a✓�.ye s�d•e Fr ZX� Ua�L� '"L6KSo�.;ra41o�� ( i l� tt�6 C AE �ju9.�P-U P2 4j S AL�Cvl-k t 6t�C 4k