7 LARCH AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 780 CMR SALE
Revised Mar 2011
1/ Building Permit Application To Construct,Repair, Renovate Or Demolish a
b� One-or Two-Family Dwelling
1 This Section For Official U Only
Building Permit Number: Date Ap ied:
Building Official(Print Name) ' atur
SECTION 1: SITE INFORMATION
1.1 Property Address 1.2 Assessors Map&Parcel Numbers
-7 L_tk2G,1,.1
Lla Is this an accepted street?yes r/ 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:
Zone: _ Outside Flood Zone? Munici a n site disposal system
❑
Public,B' Private El Zone:
if yes6' p P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: )
IHA a1990
Name(print) City,State,ZIP
1_ 4/1G,W Ave,, !78 578./01�1 b�N6.�i��1gi3Y�f_ B / Gou�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repa;s(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : O }�
au u '
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ _ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 6/ y5�. 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
c C.5 —D i 3 083 0 o SF
License Number Ex imtionDate
Name of CSL Holder
f/ List CSL Type(see below)
6(o ��t�(�jO2iJ ST No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
ep I q7 b R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
q fj I Insulation
Tel hone s—r� E ail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/Ot'oBoG Z 7o/Z
a om G'OD S A&-mg HIC Registration Number Expiration Date
HIC Co many Name or HIC Registrant Name
�.�I Str ao W Q/9� 9;y 7vi� mail address
Ci�y//T[[own, State,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 ..........Br No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize- ET�l2 69 'Ag
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print ner's Name(Electronic Signature) Date
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 understanding. /
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dos
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 Siux"Nl, NLkSSACHUSETTS
• BUUJM IG DEPARTMENT
• 120 WASIMNGTON STREET, 3" FLOOR
T FT- (978) 745-9595
FAX(978) 740-9M
(O-tgFRf FY DRISCOLL
T
MAYOR Ho&w ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BU11-DING CO%L%USSIONER
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:
Z-I
(name of hauler)
The debris will be disposed of in :
(name of facility)
27 U/,4i s7- ;��Pz
(address of facility)
signature of permit applicant
Z+O<Z
T~ date
dcbrwir.dm
CITY OF S�U.Eitii, \L�SS.�CHLSETTS
MILDING DEPARTSIENT
120 WASHINGTON STREET, 3m FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
ICI\tgFRi RY DRISCOLL THOMAS ST.PMRRB
MAYOR
DIRECTOR OF PUBLIC PROPERTY/HL'ILDLNG COMMBSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Deli.
Name(Busim'ss:Organization/individual):
Address: 1a 6 76.dK 600-0
City/State/Zip: , 4ti AO D/970 Phone #: 7y/ 1�99
Are you an employer?Check the appropriate box: Type orproject(required):
LEI❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(fill and/or part-time).• have hired the subcontractors
'2.9-1 am a sole proprietor or partner- listed on the attached sheet: 7.;RRemodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
workingfor me in an capacity. workers' comp.insurance. q
y p ty. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑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
comp. insurance required.]
Any applirard that chocks box#1 must also fill out the section below slowing then worker'compensation policy infutmation,
'I lnmeawnen who submit this affidavit indicating they ate doing all work and then hire outside contractor must submit anew affidavit indicating such
=Contmcton that check this box must anachod an additional sheet showing the name of the sub-contractors and their worker'comp.policy infomation,
l am an employer that Is providing workers'compensation Insurance for my employees. Below is the pollcy and fob site
information.
Insurance Company?lame:
Policy#or Self-ins.Lic.M 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 a
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$250.00 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.
l do hereby certlf under the pains
nand penaltles of perjury that the information provided above is true and correct
Ci•n•mtre• V; D._J. — Date: li/ZO�ZC/7_
P o #:
Official use may. Do not write in this area,to be completed by city or town of Aciat
City or'rown: Permit/I.1cense#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cilyffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: