89 LEACH ST - BUILDING INSPECTION 5 1 'Z-(o C-
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards pr;r ra ;(J
Massachusetts State Building Code, 780 CMR ry p�Lr ;a#J 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One- or Two-Family Dwelling ZOI' AUG — I A 8: 2 2
This Section For Official Use Only
10 Building Permit Number: Date Applied:
l
i Building Official(Print Name) Signature V Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
� EAGi
I.Ia Is this an accepted street?yeses 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:
Publi4L Private❑ Zone: _ Outside Flood Zone? MunicipalA On site disposal system ❑
Check if yesK,
SECTION 2: PROPERTY OWNERSHIP'
2 1 Owner'of Record:
PAPiAlJ)Jr. �LLA -rt`e�Eaua SA-L�r A4,A O t4-70
Name(Print) City,State,ZIP
(�/ � �S� . 97875�5�I/a28 6Pi.t+ p�tuotu oos��a
No.and Street Telephone Em1•il Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied)S I Repairs(s) ❑ Uteration(s) RL I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ti, In
VAIAEr" x"
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 'D 170 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ OU. — ❑Total Project Costa (Item 6)x multiplier x
3.Plumbing $ 1,i eve). — 2. Other Fees: $ �
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
I� CT�Jz ® t J�ei l n'D130 3 OS/6
License Number Ex ratio Date
Name of CSL Holder
1D(!J
/ List CSL Type(see below)
���l"J U KK �T.
No.and Street Type Description
5-^_ � ��� U Unrestricted(Buildings u to 35,000 cu.ft.
fT M Q[ R Restricted 1&2 Family Dwelling
City/Town,State, IP M Masonry
RC Roofing Covering
WS Window and Siding
G SF Solid Fuel Burning Appliances
7 O US G. I I Insulation
Telephone Erfiail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /
0W/1DDrlaf LUS O` ,P� �Dl Bd6 7 d at ao/te V
HIC Registration Number Expiration Date
/HIC Com any Name or HI R gistrant Name
No. d Street E ail address
�5i WW 0/970 9787Y/i 5
City/Town,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 .......... Q� No........... ❑
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 L�) 1�Z,4,;Zr)
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print-Owner's Name( lectronic Signature) Date
SECTION 7b: OWNEW 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.
Ae�--%ae r4'r/J�/ ' J 7,29-16
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. ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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"maybe substituted for"Total Project Cost"
CITY OF SM.&M. N'LxSSACHUSETTS
• BUILDIING DEPARTNELNT
a 130 WASHNGTON STREET, 3'D FLOOR
'ILL (978) 745-9595
PAX(978) 740-9846
Kl,%jBERLEY DRISCOLL
MAYOR TH016W ST.PIERRR
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG COMMSIONER
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
l It, S 150A.
The debris will be transported by:
sy�l.QaorG�1 .;��a�
(name of hauler)
The debris will be disposed of in :
L q /-)o '
(name of facility)
Z-'7 77� P0i411991
(address of facility)
signature of permit applicant
/;
date
dcbri.lMdm
CITY OF Siu E.Nu. NLASSACHUSETTS
gUUMLNG DEPARTMENT
120 WASHINGTON STREET, Via FLOOR
TEE- (978) 745-9595
FAX(978) 740-9846
KIN BF-RL.EY DRISCOLL
MAYOR THom s ST.P[ERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busimbss:Organization(lndividual):
Address:_t,,L e�iAaop.-mot
City/State/Zip: MA 1)(070 Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(foil and/or part-time)." have hired the sub-contractors
2.R[1 am a sole proprietor or partner- listed on the attached sheet. t 7•ARemo&ling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp.insurance. 9, ❑ Building addition
[No 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 11.❑ 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.❑OWer
comp. insurance required.]
•Any applicant chef checks box#I most also fill out the section below showing chair workas'twttpensuion policy information.
t 1 fmmem, M who submit this affidavit indicating they ate doing all work and then hits outside contractors most submit a new arcdavil indicating such
=Cotnraxonc that check this box must attached an additional sheet showing the name of the subavmraaMrs and their walkers'comp,policy infamiuon.
I am an employer that it providing workers'compensatlon Insurance for my employees. Below Is the policy and fob site
information.
Insurance Company Name:
Policy 4 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 S 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 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 certl rder the pains
an�dd penaties ofperfury that the information provided above is true and correct.
ma t i� Date' 7
Phone of
Official use only. Donor write in this area,to be completed by city or town off hirL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Ileallh 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person' Phone M
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