20 LATHROP - BUILDING INSPECTION The Commonwealth ok'Massachusetts
Board of Building Regulations and Standards CITY
Massachusctt . tale wilding Code, 780 C•MR, 7'"edi ' n OF SALEM
ReviseJJmrnrvr
Iuilding Permit A )I on T Cunstruct, Repair, Ren to Or Demolish a l. :/N1Y
One-,
Trvu-Family Owrl!!
��✓// ThiA S tion For Qfry,&Use Only
Building Permit Number: ate Applied: //�
Signature: izz `I.1 V' I
Building C missioner/ n t of Buildings Date
)SECTION 1:SITE INFORMATION
1.1 TperAddress:
Mi 1.2 Assessors Map dt Parcel Numbers
1.1 a 133 this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(it)
From Yard Site 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❑ On site disposal system Cl
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2 Owner'of Rao
C/ �U 7 22 ,.f.pn a L �� Gi�bP S� �P/Q
Nome(Print) A rem for Service:
t
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check aB that apply)
New Construction O Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Unit_ Other ❑ Specify:
Brief Description of Proposed Work':
L/ SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCIal Use Only
Labor and Materials
I. Building S 1. Building Pennil Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
O Total Project Cosl (Item 6)x multiplier x
). Plumbing S 2. Other Fees: S���I^ JG
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S ❑Paid in Full ❑ nce Due:Outstanding Bala
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) Jq s— 1� 7 fD 152
y � /n r ( � Licenx)Numl ber F%pintiun Date
Name'ol'C51.• Ilu r N lisICSL Type lsee below)
( Deseri ion
%JJress U Unrestricted u to 35,000 Co.Ft.
R Restricted Id2 FamilyDwelling
Si muG M M thrl
RC Residential Routins C•overin
Polcphmeil WS Residential Window and Siding
SF Reiidentiat Solid Fuel Owning Appliance Installation
D I Residential Demolition
6.2 R bfe�q ;::
ractor(HIC), )q s-, /D 7
I IIC Company Nam Registration Number
Address �/' �t/ //
9�� 3 3s l7'� espi ion a�—
Signature relephxm
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL f M(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..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Si urcofowner Date
SECTION 7b:OWNERi OR AUTHORIZED AGENT DECLARATION
1 as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application oR we and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of(honer or Authorized Agent Date
5i under the sins and nalties of •u
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 have access to the arbitration
program or guaranty fund under M.G.L.c. IJ2A. Other imponant information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.RS, respectively.
�. When substantial work is planned,provide the information below:
Total doors area ISq.Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Flabitable roam count
Number of fireplaces Number of bedrooms
1.3T
umber of bathrooms Number of half/baths
ype of heating system Number of decks/porches
ype of cooling system Enclosed Open
•'Total Project Square Footage"may be substituted for"Tolal Project Cost"
%-a CITY OF SM-EN12 NLkSSACHUSF-T _rS
i3ul DLNGDEPARI-ME-vT
120 WASHINGTON STREET. 3"FLOOR
TEL (978) 745-9595
FAX(973) 740-9846
KINiBERt EEY DILISCOLL T'HOntASST.PIFR"
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILMNG CO.Ntd1ISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractor9/Electrlcians/Ptumbers
4 licant Information J� ( Please Print Legibly
Name(Busiix� Organiratiomindividual):� Ci_7 a 'l 1 S CO A_I T rCjC
Address: ! I e k-,/ U e 1
City/Statc/Zip: Phone If: �� `�3.55
Are you an employer?Check the appropriate box: 'rype of project(required):
1.❑ I am a employer with
4, ❑ am a general 6.1 neral contractor and 1 New construction
❑
employees(full and/or part-time).* have hired the sub-comractocs 7. Remodeling
2.P 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. workers'comp. insurance. . 9. [:] Building addition
(No workers'comp. insurance 5• ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
required.) officers have exercised their
right of r MGL I LEI Plumbing repairs or additions
3.❑ I am a homeowner doing all work g exemption Pon per .
myself. (No workers'comp. c. 152, §1(4),and we have no 12�ZRoof repairs
insurance required.)t employees. (No workers' 13.0 Other
comp. insurance required.)
-Any applkc tha chucks boa el most also fill out the seclioo blow showing their aorketi compmsatiun policy infutmmion.
t I lomeowners who submit this Affidavit indicting they ate doing all wont and then hire outside contractm most submit a new art davit indicaung such.
1Comractors that check this boa most anached on additiunw short showing the name of the sub-contractors and their workers'romp.put icy tnfom anon.
i am an employer that is providing workers'compensation utterance for my employees. Below is tire policy and fob site
information.
insurance Company Name'.
Policy g or Sclf-its. Lie.0: Expiration Date:
lob Site Address: J 44f hto City/State/zip: M
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
tine up to S 1,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investiguliots ofthe DIA For insurance coverage verification.
i do hereby certify the pains and ponalries of perjury that the information provided above is true and correct.
Phone 4: „� 7 IF— ..J C7 T
Official use ordy. no nor write in thir areas re be completed by city or town offleiat
City or Town: Jj2=—t/1, Pcrmiu7.lecnse
Issuing Aulharily(circle one):
1. Bourd of llealth 2.Building Department 3.City/fawn Clerk 4. Electrical Inspector 5. plumbing Inspector
6.Other
I
Contact Person: _ . __.. ... Phone B:
(
Information and Instructions
I assachusclis Gcncral Laws chapter I j2 acquires a I I eltiployers to provide workers' compensation for their employees.
Pursuant to this matule, an employed is defined as"...every Pelson in the service of another under any contract of hire.
CxprCN or implied, oral or written."
An einpluper as defined as"an individual,partnership, association.corporation or tither legal entity, or any two or more
,.I the firregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,putmcrship,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,cumtruction or repair work on such dwelling home
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
%IGL chapter 152. §25C(6)also states that "every state or local licensing agency shall withhold the Issuance or
renewal of it 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, ;�IGL chapter 152, 425C(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
Picase fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and. if
necessary,supply sub-contractor m s) nae(s), address(es)and phone nwmber(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 Depurtment of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be.remmed 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. Sclf-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:md printed legibly. 'rhe Department has provided a space at the bottom
of die 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 permit/license number which will be used its a reference number. In addition,an applicant
that must submit multiple pennit'licetse 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 "all locations in (city or
townl."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 perinit not related to any business or commercial venture
(i.e. a dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I lic t)tficc w Investigations would like to thank you in advance for your cooperation and should you have;my questions,
please do not hesitate to give us a call
The Dcparnncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
lt.,i>cd us Fax M 617-727-7749
www.mass.gov/dia
CITY OF SAL.ELI, .N LAsSACHUSETTS
• BI;R.DLNG DEPAR' M&NT
130 WASHLNGTON STREET,3'*FLOOR
TEL (978) 745-9595
Fax(978) 740-9846
Kl3(BR3r FY DRISCOLL
;MAYOR THonras Sr.PtERRs
DIRECTOR OF PCBLIC PROPERTY/BlUUMNG 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 1 l 1.5
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:
(namb bfhauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
z/a
�— date