15 LEMON ST - BUILDING INSPECTION fhc Commonwealth mmonwealth ul hlassachusclls
Board of Building Regulations and St idards CI 11'OF
Massachusetls State Building Code, 79B CNIR SALL\I
Building Permit Application To Construct, Repair. Reouvate Or Dc1 a
Me-or rn a-(unto/r Du ellinp
This Section For Of icial Use Oiilyz
Ppied
it Number: Date Ap lied: _
6
cial(Prins NIUne) S gttas Dasc
SECTION I: SITE INFORAIA IO
ddress:54 1.2 Assessors ap di Parcel Numbers
hdacre red street? es >r no flap Number Purcul Number
1.3 Zoning Inrorsnatlont 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) frontage(11)
1.4 Building Setbacks(II)
Front Yard Side Yams Rear Yard
Reytoircd Provided Required Provided Requirtd Provided
1.6 Water Supply:(M.G.1.c. J0,§sa) 1.7 Flood Zone Inrormatlon: 1.8 Sewage Disposal System:
Roblie O Private O Zone: _ Outside Flood'Lune?Check if n0 Municipal0 On sited! s)sWm 0
SECTION2: PROPERTY OWNERSHIP'
2.1 (One sofReloP ( � / S o T aG,--, /mil/-(- o( 9 r? O
Numa(Prins) City.State,ZIP S Z
i 5 �e� o Sfi �. z77x 9)_�
Nu.and Street relephone Email AJdrefs
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction 0 Existing Building 0 Osvner-Occupied O I Repairs(s) O 1 Allerallon(s) 0 1 Addition ❑
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proiposed Work':T—
N2 w IC '1 a-� G
SECTION 4: ESTIMATED CONSTRUCTION COSTS
(tens Estimated Costs: 0f11clul Use Only
t Labor and..\l terialsl y
I. Building S l ,2-r oa o I. Building Permit Fee: S Indicate how fce is determined:
'. Electrical 0 Standard CityiTuun Application Fee
❑Total Project Cast$(Item 6)x mulliplier
1. Plumhimg S , Other Fees: S_ "
1. \Ixlt.micul ill\ \t'I S List: _
�u+,nssionl S rural \II Fces: S —
Chc" No. _('luck Amount•. Cash \mount:
0 1'nWl PrnjcctCnsC S Z p C a 0 P.iid in Full 0 Outstandiog lIaLmce Due:
SECTION 5: CONSFRUCTION SERVICES
5.1 Consl ruc lion Sullen isor 1.icellse((*Sl,) C e;, 6 Lf
-W-V-11.4c Norther - i
Naoic ol'k SI. I Io Ider 1 1,1 L'Sl. I*%IV(1&
k Pit
Desvriplion
qo. and.Sircd 1nrq:%lri0k:J I lluildin s iii it,33-000 lll
51 G , R Re.strwled I-"
%I Slasoll
RC it,xilio t',ii,ving
1AS wilidow.in,"li".
SF Solid Feel Ilurning,lipplialices
C? I Insulation
Folailadtfrux4 1)
Nklillone IV*
1 7�
5,2 Registered ilume Improvement Co trri ic_, tor(HIC)
I IIC Compin) Name or I IIC Rqklruot Njing
No.and Street Sa/'^ �_ t:m4il address
City/Town,State,ZIP rei hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atlidavit will result in the denial of the issuance or the building permit.
Signed Affidavit Attached? Yes..........CI No............ NIPLETED WHEN
SECTION 7m.OWNER AUTHORIZATION TO BE CO
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.
Print 0%incir's Nkinne(Electronic Signature) Dille
SECTION 7b:OWNEWOR 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 i iteand curate to the best or my knowledge and understanding.
6 — Q__
lion
Print 0vilict'i orAllillorilvd Date
NOTES:
I. ki"I
lin Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
In
inot registered in the Home Imprui,clilentContracturlHIC) Program),will nuhave access to the arbi tral ion
registered
program or guar,oll) lolid under ill.G L. c. 142..1,. other important information on the HIC Program can be found at
I Information an the Construction Supervisor License can be found at moo\ J11,
2. %\Iicn substantial work is planned,pruilide the information below:
row floor area I ill. 111 - __—_"._t including garage, finished basement attics.Jocks or perdu
Gross lining erca 154 11 1 Habitable room count
\limber k)I'll rvillak:cs Number kit hedrooms
\Lonherol bathrooms \11111b%:r o0mll hailli
I k licot'haling S%Stein \1111ii,cr o(Jecks, porches
01wil
I' pcitVill
I olA Prilico Squall:Fool'ice,lll;,N be oh,toutk;d 1kir Project CoNt"
s BUILDING DEP. UNW-NT
120\' ASHLNGTON SPIEET, 31e FLOOR
F v((978) 7 N)-9844
.,j.%j3 Rt FY DRISCOLL
�,L�YO.Z TFiO�L\S ST.PIERRB
DIRECTCR OF PCBLIC PROPERTY/8CR.DNG COSL%HSS1ONER
Workers' Compensation Insurance A1Tidavit: Builders/Contractors/Electrlci•rn+/Plurit
1 ) )Ileant Information I ase Print Legibly
,VIIInC(nallll¢+tt)!�ylmrtlleh lNllVldtlall• ���I�S/�1 2. C O'^ �7 '
Address: S3 l r 6- , f C�,Y
CityiStatc/Zip: Nlk PhoneN: 99c) 5
,tire you an employer!Cheek the appropriate boss Type of prnJect(required):
I.G1 I am m employer with 1 a. 1 am a general contractor and 1 6. Q New construction
aotployces(I611 and/or part-lime).• have hired the sub•contnctars
2.❑ I am a Bole proprietor or partner. ,
listed on the uttachad+heel t L M Remodeling
.hip and have no employees These sub-contractors have 9. ❑ Demolition
working rot me in any capacity. workers'camp.insuronee. 9. Q Building addition
I No workers'.comp,insurance 3. ❑ We are a corporation and its
requircJ.j oiRcen have exercised their
10.0 Electrical repairs or additions
).❑ lain a homeowner doing all work right of exemption per MGL 110 Plumbing repairs or additions
myself.(No workers'comp. C. 152,91(4),and we have no 12.❑ Roof rupeirs
insurancerequired.jr employees.(No workers' I).QOther
Gump, insurancerequin:d.)
•.vny appll.artl lid chwkr box*I must A w all am the mclim bulaw ebowina their waYan'wmpanwlun pulley inaomaaoh
'I b�.nuuwn v who.ubmit tlex ulldavit Indicnina they are doine all uvrk and then hire aunids canlmetare midi rahmk a raw 301davil indiwina.udt
erton that chvet this bus must aaxbod an.ida illutud.hail showing the naea at ills rab.wnlracWM and thalr wnders'wrap.policy Infixmallon.
I urn un eurpluyer that is pruvfill Ivorkas'rutnparradun lnsarunee%►my empluydex Below l:the po//ry andtub)'!H
lnfaarrutlnn.
In.wrancv Company?tmne:-/4 Z- ,,.._
�/C C Sdb �J 55 �( � 012
Policy 4 or Self•ios. Lie. 4: / c� Expiration Date: /
Job Silts Address: j LRr �^ l� City/StateJ2ip: ez,-,-e
.\ltacb a copy of the workers'compentatloo pulley declaration page(showing the policy number and espindon dato).
F.iduru to,vcury cuvdrage as required under Svction 29A of bIGL c. 152 can lead to the impositictn ofcriminal penalties of a
rime op to i 1,500.00 und(ur one-year imprisnnmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a lime
of up to S230.110 a day against the violator. Ile advised that a copy of this m4lemcnt may be(urwardcd to ilia 00%a of
I n verb gadons,I('I lit: DIA 6)r Inxuratice co ve(aga veil licallan.
!du hereby a•rrri�y rurJr� a lalrlr.r nIprrjury that Jrs!n/unnuNun pruvideJ about is nut auJ•artist
i:r,ihrtc: tn� c� c o Dam:
011h ial,ue only. !ha not write,in this area, rube completed by city of ldwn nlfJciu2
City nr 1"nvn: _ -. Pcrmitli.lcense 4
I.1uin-.\ulhurily (circle ono):
I. Iloard of 11evllh S. Iluildiny Departmcnl I. ('ily,Tolan Clerk 1. Electrid.11 In.pecelr i. Phoohinq lotpector
fi. Other _ ..
i
('amass I'ertan: .----_-..._ Phone r:
CITY C7E 5.1[.E.�i, AUSACHUSETI'S
t3l'tL0LVG DEi•.1RTlF.\Y
I _'0 'r-UH0ICTON STXW, 1"FLOOR
` 11L �97817�1.9S9S
KEM31_AUY MWOLL F,Vt(973) 7449SU
.MAYOR INa.+W ST.PMUS
DiucroR OP PC suc PROPERTY/aC2DLVG cOS011s1lONER
Construction Debris DIV0821 Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edigon of the State Building Code, 190 CUR section 111.1
Debris, and the provision$of UOL a 40, 3 14;
Building Permit a is issued with the condition that the debris resulting from
this work shall be disposed of in a prope
I 11, S I JOA. rly licemed waste disposal facility as defined by NICE c
The debris will be transported by:
J
(name of hauler) }
The debris will ba disposed of in :
(name al'lac[il-' �
t,ddrers air n„t„y� /
narure ul;,ermit rpph.rnf