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1 LINCOLN RD - BUILDING INSPECTION (2)
�,�i�d ��'�.� � + � �1� �, . The Commonwealth of Massachusetls � - Board of Building Regulations and Standazds C� � Massachusdt5 State Building Code,780 CMR,7'�editidn R��d� d . Bw7ding PermitApplication To Conslruct,Repair;Renovate Or Demolish a I,2008 i ' One-or Two-Fmnily Dwelling �' � . :'. . _ . . �- :--C. . "IbisSedionFotOfficialUseOnly '� . . : � � � � Bu�ding Permit Nwnb�i-.. _:. .: .. � .. Date Applied: . ..._ . � `.. ...- . . . . .. � . s��,�: _ `�� - 0 /3 __ ]:BuildingGommissiover/.I � ofBirild'mgs .._... Date - � . _ _ SECI'ION lr STfE INFORMATION �1.1 pe�ty... Address: � . . .. � � 1.2 AsseSso�s Map&-Panel Numbers . . r 1 Li n i nl n���� ss�so l.la Is fhis an accepted sVeet?yes ✓ no �P N�b� Parcel Nwnber 13 Zoning Information: - 1_4 Property Dimensions: Zoning District Proposed Use Lot Arra(sq ft) Froniage(ft) � � � - 1S Baild'wg S�tbacks(tt) � � . - � ' . Froitt Yard� � � . Side Yards -- � � Rear Yard . . . Required Providecl Reqwred Provi�d Required Provided 1.6 Water Sapply:(M_G.L c.40,§54) 1.7 N9ood Zone Information: 1.8 Sewage Disposal Sys[em: � Public❑ Private❑ - Zo�: _ Outside Flood Zame? Mimicipal O On site disposal sys[em � - � Check if y� - � � . � �-SECTION 2: PROPERTY OWNERSHIP� - 2.1 Owne�of eco • . . ` /l � L lnro�n 1��,� . Name(Print) � AdNess for Secvice: , — c/ �1`?S'`1�-1 —5��� I � - � � Telepho� - - - SEC1'ION 3cDESCRIP[LOM OF PROP(DSED WOI2IC2(cheek all tpat apply) ' New Construction❑ �Exis[ing Building� OwnerAccupied CQ Repaics(s) ❑ Alteration(s).S) Addition ❑ � Demolition ❑ Accessory Bidg.❑- 'Number of Units� .. Other ❑ Spwity: � � . .. Brief Description of Proposed Wmi�_ Tn�� �1 o c rna,r a��- O a-4l, -Fa 2° F�eer' SECCION 4:F.STIMATED CONSTRUCI'ION COSTS ' I[em , . Estimatecl Costs: Officiat Use Only.: _ � � r and Materials : . � . . - - . . . . . , 1.Building $ I g OOd .ljl/ 1. Buitding Peiinit Fee:$ ' Indicate how fee is detertnined: � 2.Electrical � . . _$ . . � - ❑Standaid City/1'own AppGcation Fce . . . - .... � ❑Total Project Cosl;(Item��x mu/tiplier..-. x.: - . ... .,.. -. �... .� ��. 3.Plumbin8 $ , 2. Other Fces: $ 4.Mechanical (HVAC) $ � �Lis[: ... _ . . . . -.: �.or 5.Mechanipl (Fire � �Total All Fces:$ . . S ion $ p- - � .i Check No. - G9�eck Amoimt:. Cash Ama�urt: �. 6.Total Project Cost $ ` p pazd in Full ❑Outstanding Balance Due: � SECI70N 5: CONSTRUCTION SERVICES 5.1 Licensed Constmetiou Stupervisor(CSL) p y 6 6 03 S-�' ►3 J 0.`K�e.�J '��SW A�� � License Number Exp'vation Da[e � Nmme of CSL-Holder 1- ;v � . � G(b«� � - �J2 S�l I� . V� A Lis[CSL Type(sae below) � _A, . Address . �. T , . �on � �• �jf� , . . U Umestricted to 35,000 Gli.Ft. - . 9tn+�r. ed/�� R Restric6ed 18c2 F�i Dwellin M Onl s� 978- 73s—a35T xc ���x� co�� Telephoffi � ,_. . .:•.�'. � WS Residential WmdowavdSidin � , . . SF Residertiai Solid Fuel Bumm A liance Instailation - - � D Residentiat Demolition 5.2 Re¢ist�H��;I�pmvementContraMor(�G7 � G q7 a� �`�� . \uCc`5 Ti,G � HIC Compeny Name or C Registrurt Name Registr-ation N�mmber � t..� Cross �oz S'cele.w�� /hR Ot`t7v 7�;27�a6�3 aaa�ss �.,y,� �,,. � g�s-73s-o3s Fx���on naze Signattve Teiepho� SEGITON 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L�152.§ 25C(�) Workers Compensation Insurance affidavit must be completed and submitted with this appliption. Failure to provide . this affidavit will result in the denial of the issuance of the buiiding j�eimit.� � Signed Affidavit Attached? Yes........�..�` -No----.----.-� . . . � . SEGTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WFIEN 'I OWNER'S AGENT OR CONTRAGTOR APPLIFS FOR BUII.DING PERMI'P I, as Owner of the subjec[property he�eby ' authorize to act on my b�alf,m all matters� - � relative to wodc aWhorized by this building permit appliption. . . � i Si of Owner Date � � - SECI"ION 7b:OWIYER'OR AUTHORIZED AGENT•DECLARATION I, ^�e�w�s H'�W c�a� ,u Owner oi Authorized Ag�t hereby declare thaY the sfatements and information on tl�e foregoing appliwiion are true and acc�uafe,to the bes[of my lmowledge and � behalf. n ( � �—G�' �M 2.S L1.._\«)ii8 . . . . . . . . p__j � PrintName�.Iiltx� W_ � 1�,7`.�� .Sigoabaegf�OwoerorAWhoriacdAgen[' � Date Si �mdert6e ' and 'esof ) - _ NOTES: 1. An Owner wLo obtaios a building permit to do his�hex own wock,or an owna who hiies an�m�egis[ered contractor (not registered in the Htime Improvetn�t Contrador(HIG7 Program),will naJ have access to the azbitration pragram or guaranty�fund under M.G.L.c. 142A.Other impoNant information on the HIC Progracn and Construction Supervisor Lic�sing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I l ORS,respectively. 2. Wh�substantial work is planned,provide the infortnation below: Total floors area(Sq.Ft) (i�lud'mg gazage,finished basem�Uattics,decks or porch) Gross living area(Sq.Ft) Flab�able room count Number of fireplaces � Number of bedrooms -�� N�ber of bathrooms N�bw of half/baths Type of heating sys[an Nwnber of deckc/porches Type of cooling system Enclosed Open 3. "Cotal Project Square Footage"may be subs[ituted for"Total Pmject CosP' . t / CiTY OF S��I.E.ZI� li�3SS.�CHI;SET'TS '- � . B[.-[[.��G DEr.�ala�v"c 1�W_�3L�iGTON STBEEc,3aD�.oOR �� ��� •� - 'i�- (978�745-9595 s . FAX(978�74Q-4846 . , ��Rt �t DRTSCOLL : . ' =, , , _ . , � J i1r�s1YOR �' , , -.,•,: _ _ T1iObLtS ST.P[ERxE DIStFCi�BOF�:BL[C PROPERTY/BCIIDL^SG CQSiSQSSI01iHR �� ,-1... ,� . ... .. _ � Constructi�n Debris Disposa! Affidavit - (required for all deinolition and renovarion work) z In aceordance 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 Per�nit# is issued with the condition that ths debris resuhing fmm this work shatl be disposed of in a properly licensed waste disposal facility as defitted by NIGL c 111, S 150A. The debris will be transported by: � I.�c'�si�¢, C Ar��no, . , .... . . . . - :. _ (namc of hauter) - - �- — . ... . , . . ,r .,� The debris will be @isposed,of in : T�S�� �-�•o� {name oF facility) SW c�rrmp <O� ,lZ� , �c�i`�'�'� (address af facili ) d!! C/� signature of permit a�licant ,.- ..•.� .� �D - 7 - 1� ' " .,:., date Jcbri�IF.diu f , CTTY OF S.�1LE:`I, 1��1�1SS.-1CHL'SETTS •- � • &:u�stGDEr�a'racE.�'T l30 WASHINGTON STREET,3tD F100R `� TeL (�78�745-9595 _ FA.`C(9'7�7�10-9846 lC1��ERI.EY DRLSCOLL � ib1RYOR 'I�tOed,ic ST.PiERRB Dcnuroa oF Pt:euc rnnrExn/B�u.Dnvc coa�assta�� a — - - —. . Workers' Compensarion Insurance Afftdavit: BailderslContractora/Electrician�/Pinmbers Annlicant Information Ptease PriM Leeiblv �I�iY10�Busitxss:Or�ni��o+ulnJividual); ��� �J���pR�S �.r�G Address: �I Gro 55 �v2. . � c��y�s�t�z�p:S�.\e� M A o��io n��p: q �8 .. 73 S •0 3 5'T Are ou aa employer?Check the appropriate boi: Type of proJeet(required): 1.�1 am a employer with � 4. � I am a general conocac�ar and 1 6. ❑New conxvuction employcea(fuli and/or ryut-cime)•' have hired t1re subcontraunrs 2-❑ 1 am a sote proprietor or paztner- listed on che attaehed sl�eet� 7. �Remadeliu,g ship and have no employees T1rese snb-wntractors heve & ❑pemolition working for me ia any capaciry. �vorkers'comp.insura�rce. 9. []Buiiding additioa (No wo�kesa comp. insurance 5. 0 We are a co[parntion aqd its 10.❑Electriral re irs or additions nxryiretl.j officers have exercised their � 3.� 1 am a homeowm:r doing all work cight of exemption per MGL !I.�Ptumbing repairs ar addiciong myself.(no workers'cmng. c. i 52,�I(4),and we have no �Z,�Roof m�i�s ins�uiance require4}t cmployees. [A'o waikers' t3.0 Ot}� comp.insurancerequirod.) 'nny appliwq tAat t�xks bm[!t muct ako fill aut the seetiom bdwva8uwing theirarorkoa'compenuuon poliey inturmatlon. !14xnrowocn whu suM�rit 16b aflidavi[iMioting thgm devmg all wpek yW thra hix ou�5idecipntr�ctoia m�W su6mk a new n1R�v9 i�dialing a�dt �Gm�m�.�tun tAat aiust�6ia bme must aqxlxd m�dditiad ehat ahowing the�uoeof dx sub�oDnWaae aod tM6 woAre�s'comp.poliry inhmutloa 1 um a�r emplayer that ir pmviding worken'compeneatran lnauranct for my earpfoyeex Below Is rhs po[lcy and Job s![e injo�maeinn. t�_ tn.wr�nce Company Name:.. �—` �7 e���-1 'N�v�c' � ot� Policy N or Self-ias.Lic.N: �/�C cri— ��S� �J�7 d�S,5"OZ.�Expira[ion Date: 7' 3 0 � I '2 ' !ob Sice AcWress: CitylS�aWZip: Attac4 a copy of lhe workers'eompemalloa poliry declarallon page(shawing t6e polley aum6er and esplratfon date� Failure a xzuce covetage as required under Section 25A of MGL c. 152 can lead w lhe impositian of criminal penalries of a fine up to 51,500.00 and/or one-year imprisonment,as well as civi[penalties in t►ie foxm of a STOP WORK ORDER arul e fine of up ro 5250.00 a Jay against tlu violaror. tie advi5ed[hat a copy of ehis Maeemrnt may be foiwarded co the Off ice of Invcstigatiura uf the DIA for insurence caverage v�ifinatioa 1 do he�eby cerN�yy rurdti f/�pnlaa anJ penal�lu ojperJary dia!the 6ifo�matlon provldrd above Is wrtr un4 co�reK � ,� , i�irv..�-� Dare in -s �� Phone�: �� � ' ��JS � ��Jr7 O�cid uu only. Do not wrife!n rhts weq m be conrp/c[ed by city or town oJJruiaL City or Town• permidl,iceose 1{ lssuin�Awhority(circle onc); I.1Soard o[Ilrrll6 2.Building Departmrnt J.City/I'owq Clerk 4.Etectricnl Inspccror 5.PlambinA Ipspeetor b.Ot4er CuntaM Person: Phone il: � - ._.._� ._ _ _ __ _ _ ,�; ... . . _ ,, ,�:�'==w "_ v�ti::zo .s ���: /� P��� ' > �t��` DAVID F. � y J.4qUITH � � ; ';,�`ry tvo.2853 .n � ��� �R„wury MA .� �� , . ___. � . . -. � . ; � .�_ T_.. ..� 3+� � �y, �- __. �=�- -- �.__ ____ -. � __,_---- -,�,...�„✓ t3'F- . 1�:r,�ori� v�-r , -O avid F �� �w _.+-�rf+►nrtt�l 1��{a� 12 / \ -�ar,tr� -{c���_-�� . ____ _..___ __ b _.__--.________..._ . {�' ,�;.<,�`.�, , ; � ��� � _ _ _ . I _ .� — �-y�-�t�at.-r-.:.-� -_. _ _ __ .._1����-. �t.r.�G7r - _ ___=-- � _ � - _ i ac�uith �-_�_._i._ � _ �\ `•f�-1s�fG� _k�`�C �h��- _ VrN'P' ::_ i „!��.1C/' _ �,.'i4?� Y'arRi.i '� __._ ._ -- _ � , � " r - -\ ,r�s-°-n!G' - w�vwt�n. 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