8 LEMON ST - BUILDING INSPECTION I I The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,71"edition Ois SALEM
t( Revised January
i Q}' Building Permit Application To Cons Ict,Repair,Renovate Or Demolish a 1, 2008
I One-or Two-Fainily Dwelling
This Section or Official Use Only
Building Permit Numbe Date Applied: /L V
.Signature:
Buil m o issio r/Ins M
for clf Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers -
2 LEr%oN Sj SN.6Pt t7J. _ -
I.la is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(it)
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 OI�wner'of Record:
"t 'Cl T.it r, C.W—P5 % LCnu° Si. SAL cn rl
Name(Pnnt)''1 0 Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: i PSul�S: C'�14yNI R���btNk ,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 3 0Ob 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost"(Item 6)x multiplier a
3. Plumbing $ 2. Other Fees: $.
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire f.2
Suppression) $ Total.All
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ Ob d ❑Paid in Full ❑Outstanding Balance Due:
-� SECTION5: CONSTRUCTION.SERVICES
5.1 Licensed Construction Supervisor(CSL)
�
License Number Expiration Dale
Name of CSL-Holder C
6')01 t,,�.as p$�ia^' Sj. S T E 2 Ill K-11" a 9'>d List CSL Type(see below)
Address _ Type _ Description. t
U Unrestricted u to 35,000Cu.Ft.
7
R Restricted 1&2 Family Dwelling
Si a[ore M Mason Only
(rota) 4 tl L 1141 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
N,r-- Hsne R>x(cziu tr Svc.
HIC Company Name or HIC Registrant Name Registration Number
L')l ( nsNw 'r 5T. s5E 8[11 / S�ta3tro P2 01h3 11 / I ZD1�
Address (Sbe) y0t. aii) Expiration Date
Signature / 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 ......... No...........❑
SECTION7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, R)y v o� k, 0- o V%Vt 01"s as Owner of the subject property hereby
authorize JAOhE to act on my behalf,in all matters
relative to ork authorized by this building plormit application.
lX �/I / / c,
Si ature of Owner Date
{SECTION 7b: OWNEW OR AUTAH'ORIZED AGENT DECLARATION
I, P-E_ H 0h6 as Owner or Authorized Agent hereby declare .
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
> h z IJAw t4 Fof� / >,F. l�enF r�6)�_f oat wnt6 S�(,
Print Name ,{ - � /(y h Ol
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of e
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations l I0.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.mass.govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please
- Print Legibly
Name(Business/Organization/Individual): NEW t(/6VadD HOh1 �014"Allfl_ iT.It_
Address: (,ti ) (,) AS4^'tlW�J Si- SiE 8111
City/State/Zip: �, TL6T3yro "C 61t10) Phone#: Not) 40�- 11119
Are yo n employer?Check the appropriate box: Type of project(required):
d2 I l am a employer with 4. El I am a general contractor and 1 6. Q New construction
employees(full and/or part-time;.* have hired the sub-contractors
2.0 I am a sole proprietor or partner-
listed on the attached sheet.t 7. 0 Remodeling
ship and have no employees These sub-contractors have 8- 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
required] officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employ ees.,[No workers' 13,FerOther INSVI.at T) pQ
comp.insurance required.]
•Any apphcam that checks box#I must also fill out the section below showing their workers'compcnsetion policy information.
I Homeowners who submit this alFdavit indicating they arc doing all work and then hire outside contract.most submits new affidavit indicating such.
iContumous Nat check this box must attached en additional sheet showing du name orahe subcontractors and their workers'comp.policy info manors.
lam an employer than is providing workers'compensation insurance for my employees. Below is the policy and job site
information.Insurance Company Name: /A6
\ 6Tt(tda 21�hf(.pt �NSVRat'L6 7
Policy#or Self-ins.Lie.#: ��V R -'ri 16� p'1 >y 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 25 A 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 and pa s and penafties of perjury that the information provided above is true and correct.
$,tgnanre Date
Phone# 0 og) tr 0 C air
Official use only. Do not write in this area,to be completed by city or town officiat
City or 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#:
Mmosachuxetts - Department of Public Safct%
Board of Building Rc�mlatioti. and Standards
Construction Supervisor Specialty License
License: CS SL 102M
Restricted to_ IC
TAMER WW"
879 WAS W. SUITE 8
ATrLEBORO,M4SVW
-•L ����� Expiration: 11/13r"2
Tr#: 102940
_----------
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
RegieVa"n: 164937 Trk 700404
Expiration. 11104011
TYPE Coffin
New England Home�Pfa�ing'•?f�;Inc.
Tamer Newer 6.111
679 Washington 9h"4 Undersecretary
Attleboro,MA 02703