118 LEACH ST - BUILDING INSPECTION (2) - ! 1 Y'7G
The Commonwealth of Massachusetts
1W Board of Building Regulations and Standards R CCIIT OF
Massachusetts State Building Code, 780 CMR LN$PE E f9 $
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling Zan DEC _2 P 1: 5
This Section For Official Use Only
Building Permit Number: Date Applied:
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Building Official(Print Name) Signature Date
(o SECTION 1:SITE INFORMATION
1.1 Prope Addres : 1.2 Assessors Map&Parcel Numbers
X o�ea-clk i* ,
L Ia Is this an accepted street?yes no Map Number Parcel Number
1 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
1 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�Ca u 1,6,L0A Sa /ern t ?V1c
Name(Print City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: GS r re• Ace .
Brief Description of Proposed Work': A.e n/eee— Rocs.+ a-F-oA
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ �s-vo 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
Anro ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ svo 2. Other Fees: $
4.Mechanical (14VAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 02 7 SO ❑Paid in Full ❑Outstanding Balance Due:
Lo,L.(... W1{E31J CCA7A1:'1VkA , Crag.-GP [21ci j LYYIOYr � Mt)-%L,�50 1215 Tp (\f,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
y�lr LL// s
X �
ot+.y /�-t•CwrM.,1.�Pf�- License Number Ex irati nDate �
Name of CSL older (//, V / Dn List CSL Type(see below)
No.and Street Type Description
jV
Rec [1n>7 i �� ot8sy Unrestricted(Buildingsu to 35,000 cu.ft.)
ok . R Restricted 1&2 Family Dwelling
City/Town,S� M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
97 el$y U l I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
200
,& �d'tS� e-o• _ZA/C, HIC Reg strati n Number pi Von Date
HIC Company N e or HIC Registrant Name
�9 er � �` /de
No.and Stream Email address
Alfl, Ko , /11e olBSI fn-66s 83Yy
Ci /Town,State,ZI Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be ompleted and submitted with this application. Failure to provide
this.affidavit will result in the denial of the Issuan a of the building permit.
Signed Affidavit Attached? Yes .......... 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 xxlko `y 6'jtn va//PS'G
to act on my behalf, in all matters relative to work authorized by this uilding permit application.
A'e4y, Jaib't-� / t
Prints Name(Electronic Signature) Da e
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 hives 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
mn .mass. og v/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"
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Department of Industrial Accidents
Office of Investigations
600 Washington Street
J.
Boston, MA 02111
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� / Please Print Legibly
NtlMe (Business/Organization/Individual): Xay comyt. co. '/r•
Address: PD ff Seyqr
City/state/Zip: &A6611w5 t M Phone #:
Are you n employer? Check the appropriate box: Type of project (required):
1. am a employer with 3 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling
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.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 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' 13.0 Other 4GS /+/e
comp. insurance required.] T— t
'Any applicant that checks box ill must also fill out the section below showing their workers' eompensetion policy information:
t Homeowmers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tContraciors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp,policy inforrrrrtion.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information / 1/
Insurance Company Name: L /�ilCuw� �Sti/4�ee�
Policy # or Self-ins. Lic. #: a1C, - ?Is-32k9 087 -Oa y Expiration Date: 1 a6 �Sg-
Job Site Address: �� ,.�u� S� City/State/Zip: S'G /••�
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 $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 certifyy/under the pains and penalties ofperjury that the information provided above Is true and correct:
Signature: Dater
Phone#: y�g3�11
Ogicial use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6. Other
Contact Person: Phone#: