9 LARCH AVE - BUILDING INSPECTION (4) Ep
I he('oounomsreallh of massachuselts
Board of Building Regulations and Standards
errs OF
Massachusetts State Building Cute. 7SO CNIR Kari. J.IGu
One.
rr ' l
Building Permit Application To Construct. Repair. Renovate Or De ms s a
ie•or rnn-F2unilr Direllin•\r
This Section For 017icial Use Only
Building Permit Number: Date Ap lied: _ 7
(Building Oliiclal(Print Marc) I O� Sigtr Bute
SECTION I:SITE INFORSIATION
1.1 Property Address' 1.2 Assessors Slap& P ctl Numbers
'r,e 4 �4�e_
I.la Is this an accepted street?yes no Map Number Parcel Numher.
1.3 Zoning Information. 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arco(sq Il) Frontage ill)
1.5 Building Setbacks(n)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.t.c.40.§14) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check it'yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 //O��wnerl of//RecQr A /
Nwne(Print) City.Stale.ZIP
No.and Streel Telephune Emuil Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 021f Allerationts) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
f' lvrraVe4 kv171 Air -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
lidos Estimated Costs: Official Use Only
I l.abor and .Materials) y
I. Building S y j'di — I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City!Tussn Application Fee
(3 Tuml Project Cost'l Item 6)x multiplier _ -- x
1, Plumbing S 2. Usher Fees: S -
J. Mcclialwal ill\.\(•) S List:-- _-_—_
�. Alcchaniccd IFirc S — .-- .--- -- -- _ .
Co „re5sionl Total .\II Fees: S
('heck No. Check:\mount _ ('.ish \meant:
o Total Project Cost S �j DSO, ❑ paid in Full ❑Oulst:mJiog 13.11 mcc Due:
A-11,
SECTIONS: CONS FRUcrioN SF.RVI(TS
5.1 C'onstructioliSupcnisort.icense(('SI,) Ioo/ 3
_lam q r( k� S `� -A I iccnse Nunther I ynr;uinu Iknc
j N:uneol'l'Sl. 11nulder // liill'SLllpeliechdowl.__'--_--- '.
__ y� /✓Y[th o✓ �.___ -- .. -- 'll pr I)exriplion
No. slid Ancct
Z /(� ,/�� (I I�nrcuricled I IIuilJin s a to 1S,UUt al. 11.1
4 /Y r ff /�G �� µ µe'trictO 1&2 P.wtil MwIlin
l'it�i fow n,.tilale.LlP \I \luiun
µ(' µtwlin Uncrin
Vs Windmv.utd NiJin
SF Solid Fuel Miming Appliances
Insulution
Tcic hone Fntuil address D Detnoliliun
5.2 Regis erect flume (nil) oven lit Contractor(HIC) //2 �� 6
�.ryyg t!IlG.✓.t�� p4 / �t� ( Ga-/ �fb c IIIC' Itcgisn;ttiun Numlwr f?spirWiun Dmr
I IIC'Com ? Not:or I IIJRe istrunJ7o
Nu. andY
Emuil address
City/Town. State ZIP reletihone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152. 1 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 .......... No...........O
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
to act on my behalf. In all platters relative to work authorized by this building permit application.
Print O%wei s Nutne(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pa1113 and penalties of perjury that all of the information
contained in this application is true and accurate to the essttt or my knowledge and understanding.
Print Owner's ar:\uthoriruJ.\gcnt's Nmne siglulture) Dule
• VOTES:
1. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program).will nn have access to the arbitration
program or guar lit) fund under M.G.L. c. 11?.\. Other important information on the HIC Program can be found at
www �;O% .4.t Information on the Construction Supervisor License can be found at
2. \%'lien substantial twrk is planned, provide the information below:
rota) floor area 1 sq. µal - __ I including garage, finished basement attics,decks or porch)
Gross living area l sq. tl.I Habitable room count
\,,mheroflireplaces _...- . \'untherofbcdruoms
l \uniher of hathrooms.... ..- ._. _.._ -- \umber ill'hall'hallis
11 pc of heating i)sicnl _ Number of Jccks porches
I pe nl Pa.hmg i)ilei❑ I`ncloieJ ..
Olsen
1, -loial Project Square l'ool.lge"ma) he suh.tituicd Ilir,foal Project Cast"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mnss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
NamO(Business/Organization/Individual): &V/r//lUA-,t
Address: Po 13 a< 2- 4 -2
City/State/Zip: S4 Lr✓7 i Z7�)�Z Phone#: .9 k ' 7
Are you an employer?Check the appropriate box: Type of project(required):
L L7 t am a employer with 4. ❑ I am a general contractor and I 6. El Now construction
have hired the sub-contractors
employees(full and/or part-time).• ?, Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ❑
ship and have no employees These sub-contractors have g, El Demolition
working for me in any capacity. employees and have workers' y []Building addition
o workers'coon insurance comp.insurance.t
[N p• 10.❑ Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.0 I am a homeowner doing all work dfficers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12 toof repairs
insurance required.]t c. 152,§1(4),and we have no 13.❑Other.
employees.[No workers'
comp.insurance required.)
Any applicant thin checks box#]must also rill out the section below showing their workers'compensation policy information.
I Homeowncn who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating sueh.
tcontmetoo that check this box must attached an additional sheet showing the name or the sub-cuntmeton and state whether or not those entities have
employees tribe sub-contmcton have employees,they most provide their workers wrap.policy number. -
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and Job site
information.
Insurance Company Name: zt/sr/�/c �'L � �
Policy#or Self-ins.Lic.#: f^/ /^ �y Expiration Date: f��21 z
*Job Site.Address- G L e C ) , s hi / ;�y� City'state/Zip: a197U
TT Attach a copy of the workers'compensation policydeclaration 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$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$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.
I do hereby certify a dery thhee pains and penafdes ofpe/rjury that the information provided above is true and tarred
Si nature: /`' /'L'/Gd`+ 'i Date:
Phan
O�----cc�ial use only. Do not write in this area,to be completed by city q, town official
City ob Town:- Permit/License#
Issuing Authority(circle one): _
1.Board of Health 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other -._
Contact Person:_. _ Phone#:
t
CITY OF S.1I &Nr, A"S.ICH(,'SETTS
OLQO04C OEP.%ATtE_ V?
120 WASHLNGTON STXW, J'O FLOOA
C11®ERLfiY ORLtCOLL P.kx(978) 74O.984
,MAYOR T}iomu ST.pmnm
O rlwTO tt OP Pl,auc PROPLFITY/al'QDNG cO1C31IssIO.N Elt
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7s0 CMR section 1 l 1.5
Oebris, and the provisions of MCL a 40, 3 54;
Building Permit a is issued with the condition that the debris resulting from
This work shall be disposed of in a property licemed waste disposal facility as defined by NIGL c
I 11. S I JOA.
The debris will be transported by:
(n4me ur'hauler)
The debris will be disposed of in :
(name o�rifudity)
I�dara, arn. l ,y►
iynJnue ufpermit rpplicJnt —
2i,1lz
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