10 LATHROP ST - BUILDING INSPECTION (2) :a The C'onununsveal(h of Massachuscits
Board of Building Regulations and Standards CITY OF
MaSSal'I1LISOtS State Building Code, 730 CINIR SALUM
• 'L„•, _
Building Permit Application To ConstnlcL Repair, Renovate Or Demolish u Rerised.11ur loll
One-or Two-Fumill'Du elliuif
This Section For Official Use Onl
^ Building Permit Number. D Applied: . I
� /7 /
th"Iding 011rcial(Print Marc) Signature
Date
SECTION 1:SITE INFORMATION
I.I Property Address: LfyT\-mo i5 $Z` 1.2 Assessors Map& Parcel Numbers
I. �
la Is this an accepted street?yes no Map Nalllhef —
I urccl Nwnller
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use - Lat Areas Il)14 Frontage(Il)
1.5 Building Setbacks(R)
From Yard Side Yardsi Required Front
RequiredProvided Rear Yard
Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone?
Chock if vs❑ Municipal❑ On site disposal s)stem ❑
rr SECTION2: PROPERTYOWNERSHIP'
2.t w ofKe old:
/ a
N;mlc(Frio)
Nu.,md Street —�-----
Telephone Email Addms
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Specify:
Brief Description of Proposed Work=:
PA-
IS SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(I abur and.Materials) Official Use Only
�O I. Building S ' O()p . I. Building Permit Fee: S Indicate how flee is determined:
'-. Electrical S ❑Standard City/Town Application Fee
1. Plumbing S ❑Tutal Project Cost'l item 6)x multiplier
_'. Other Fees: S -
J, \lech:ulical ill\'.\(') S List:
5. \Icehanical tFire -- --- --- -.
i ---Fees-- — --
tiut+ress $ionl total .\Il Fees: S
n. Total Project CusC $ ' Check No. —('heck:\mount: - - C,uh \mount:
V ❑Pail in Full ❑Ou(standing Bal;mce Due:
PO -00
tiEC'I'ION S: CONSFRti('TION SERVICES
S.I ('onstructionSupervisorLicense(CSL) OC -60(aQl `1 'LII3 I
----
Pc brut m I lie
Liconse Nwnhcr I ,
V;unc of CS!, I IuIJer Iist CSL f%Pe lice helo,0. V/`__----
�p.�\T(—�VJ��� h)P Deserlption
No. and Slrcet II I4treslricteJ II)uilJiu gi ti nl}),Illltl eu. ILI
µ IiearictcJ LC?Tamil D„cllin
%I ii1,
Cit)i 'mil,State.ZIP
µC• R,wlin owson ,rin
_ µS N'inJuw;mJ.tiiJin
SF Solid fact Burning Appliances
I Insulation
Finail address D Demolition
I'dc hone
4.2 Registered Home Improvement Contractor(HIC) (� �
I IIC I(cglstnalon Number I-piralion Date
I IIC C'oinpan) Nome or I IIC I(egistrant Name
Email address
No.cold Street
Ci /Town,State,ZIP Tel
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C. I52.1 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...........
SECTION 7S:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERM1IIT
1,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.
I I /12-
Date
Print Ownci s NuI le(Eleclmluc Signature)
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering Illy 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 tile best of my knowledge and understanding.
Print 0%%ner'i or:\uthoriieJ Agent's Name(ldcctronic Signature)
Dula
NOTES:
\n Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improve Contractor(HIC) Program).will 1 have access to the arbitration
Program or guaranty fund under M.G.L.c. I1_'.>.Other important information on the HIC Program can be found at
,v,l Information on the Construction Supervisor License can be found at2.
N'Iten subslatiial work is planned,provide the information below:
Total fluor area(sq. fl.l _ __--__(including garage. finished basement attics,decks or porch)
Habitable roum coullt
Groh living area Isy. ft.l Number of tledrooms
\weber of fireplaces._ Number of half baths
Number of bathrooms . . .. _ .. Number of decks, porches
I\Ile of lte;uing s)ilem - - _ Frljoscd - _tlpen
f1 Pc o1 eJDhltg icilelll
1. "I\sal Project Square Foolugc"ill;% he substituted tor"Total Project Cost"
yi
,
CITY OF S:1 zml AkSSACHUSETTS
BUILDING DEPART\IE.NT
?')' It•' 120 WASHINGTON STREET, 3'a FLOOR
TEL (978) 745-9595
F.+x(978) 730-9846
Ki-NmERLEY DRISCOLL
INLAYOR TltoslAs ST.PiERM
DIRECTOR OF PUBLIC PROPERTY/BU MDfN'G CONCMSSIONER
Workers' Compensation Insurance Aff]davit: Builders/Contractorq/Electricians/Plumbers
Applicant Information Please Print Leeiby+
Van'1t:Inusiix,.o Urganirmiunrindividual): t\h�� h�`c. � -f4r
Address:
City/State/zip:'SAI,:/M IMAr Of-00 Phone#: C[ 7Pi-3(S —is`VZ2Q
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
uployees(full and/or part-time).• have hired the sub-comractars ref
2. 1 pannier.am a sole proprietor or paer. listed on the attached sheet. : 7• L•J Remodeling
ship and have no employees These subcontractors have V. ❑ Demolition
working for me in any capacity, workers'comp. insurance. 9, ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical 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'camp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No.workers' 13.❑Other
camp. insurance requir d.)
•Any applieantnut checks box rl mu t also fit aul the ssclion below showing their workers'compenudon policy information.
'I kxneownan Who,uhntit this a@IMvit indicating ihcy aro doing all work and then hiro outride contractors mmt submit a new amdavit indicating such
c'nmmc'on Ihot chak Ibis box mud sashed an a ldiliurul shut showing the nwne of the sub.untracton and their workers'comp,policy infanrenion.
!am an employer Ilrat Is providing workers'compensation Layurancefor my employees. Below Is the policy antifob site
information
Insurance Company Name:
Policy 4 or Scif-its. Lic. 4: Expiration Date:
Job Site Address: - - City/State/zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). -
Failure to secure coverage as required under Section 25A ot',MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 line
of up to S-M 00 a day against the violator.-pe advised that a copy of this statement may be forwarded to the Office of
Invrstigatiuns of lha MA For insurance coverage verification.
/do hereby certify Under the pabts mad penaltles of perjury that the inforolutiar provided abuve is true and correct.
Ph11nC r/;
i Oljicial use only. Do nat write in this area, to be cumpleted by city or town offlciut
i
Citynrl'avvn: _ __ Pcrmir/f.lccnseq
LvsuinK,\ullwrily (circla one): - _
I. lfoard of Ileallh 2. Ilulldlnq Iiepa,imam I.Cityfrnsvn Clerk 4. Eleeh•ical Inspector 5. Phuobinq Inspector
6.Outer
II Contact Person: _ _ Thane 3:
i
Information and Instructions
>lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally, MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required, Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to till in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"ail locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves ctc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
fhe Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oftice of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Raviscd 5-26-05
www.mass.gov/dia
CrrY OF S,V-&Nf, AkawfiC,'SErrs
9LMDLNG DEPARTNONT
110 WASHLNGTON STIIERT, 1ie FtOOR
rM (978) 745-9599
X1313ERI Y ORMOLL FM(978) 7449&W
MAYOR THomm ST.PtRUA
01"r-TOR OP PLI)Ltc PItOPERTY/11L'Q.DLNG cosallsstONEA
Construction Debris Disposal AYttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I I I.S
Debris, and the provisions of MGL c 40, S 34;
Building Permit M is issued with the condition that the debris resulting from
I f, S IJOA.work shall be disposed of in a properly licensed
I
I I waste disposal facility as defined by NIGL c
The debris will be transported by:
�•-�1`TL
(numa of hauler)
The debris will be disposed of in
(name of faadily)
(�ddmr of flc�hry)
` + Nn�nrreofpermrtippl+cint
1 i^�