20 LINDEN AVE - BUILDING INSPECTION (7) \v\ S, I he C uttmunwrrlih ut Mas3uhusetts
Uoan1 ul Budding Regulrhuta dial Standards - CITY,
Massachusrtts State Buddmglude-780`CMR 7u'cdhion . OF SALEtN
Revard.& I"S
Iluilding Prnnit;ApQUcaliun T' t:un cl.'Rrpair,`Renovate or Drmulish a /. .rxtiv
TtvwfiimifYDt WnR
This'Section for O ldid Use Onf
Duililing"it Number Oats Applied
HiriWiry{:Cumtri ufDwldtrgs:;` . ',niis
SECTION IS ITC INFORMATION.
1.1 Prdperry Address j 1.2 Aueuon Mtap di Parcel Naanben "
` I:la is thisan oed stri;Ie s - no� ;` Mdp Number„ Paee6Numbei
IJ=Zonlag lafarautba I d Property Dlmeasltraa '
Zuning Dinner -'. f ropomJ lJse ' ' Lm Area(sy;Rl, Fror,
1.3•Dalldlag SNhiielu(D), ,-`:4 k,
From Yard =` Snle`Yards -::.it Yaid.
Requiied Provided,`- Requxed- ., Provided Regwrid _ Providid
1.6 Water Soppy:(MAL c.4%-f j5a) 1 7 Fltad 2 ode Isforaudoe Lg'Serrap Dbiposat Sysfeta
ZaNr:' Oyjiide Flsod Iae?
OdiiT
Public PRvak D — Municipal jlaii eke Aisposal rystem D
Cticektf eiD.-_•
36Cf10142: PROPEMO"IMHIP�
2.1 Ow err•of Record:
36t:TION DrUFSCRIPTION OF PROPOSED WORK'(eheelt all that.ppyj
NewConatnrchonD Eauung-Buildmg}l► ,OwnerUccu`pted Repun(s) D` Alteration(sj Addition'D'
Demolition A=msory-S D Number ofUmts_ `' Otker uD':Spaity.
Brief Description of Proposed Work=. - sz. $ k Pttro�+ ?�u'; rV Awl
SECTION 1'ES'1'IMATED'CONSTRIUGTION C05T8 `"r x t,= - -
Estimated Costs:, ; OlRelal"Use Oey `-
hem Labor and Mmerials,t Duddmg y S 1.S"bdo. aD' I DuilAing Permit•Fee"f Indicate hbo v fee is determined:'
2 Elecmcal' s D Standarrd ipgfifown,Application Fes
O Tatal Pro)ext Cb ,Okm 6)a mulupha ' x
Plumbin
1 Mechanical ItIVAC)." T Lot
S 'Mechanical (Eric S z
Su isian` Tmal All Fees.f
Check No: Cheek A6i I . 'Cash Amount:
6.Total Project Cosf S /8',9�� ,,;3; D Pad in:Full O OutnanJtng,Balanee Due -
;iSECTIOO,S: CONSTRUCTIONSERVICES
5.1 Lkensed Constructloa Supervkor(CSL (;!,�70r6d4 1 j B l Pt9/ 7
2oSC-W Pr �L9x(tL 17� 1 amso Number I..peal IkNe
Nwneol'C'Sl.•IHddv lmstllLllpelseebelow► C1
l7 Desari Lion
A 1_l _"""�""`I`_ .- U„ lloteatricted _tu 1S:00D:Cu Ft.
^-^'� Y C ... R: ,_ Reslrieted"Id2Fami .ITrelli • "
Si urc Z _ SSA M .. -. t1n
!-u�/xr- g3 ti ' RC RFukntialRauli Coreri ;:. .
relepMame WS ,Rirsmdemial Wimlow antl s. .
. � SV ReiidWW'Sulld Furl Be A iauee Imwtlation -
D. " iResidential Demolition
S. Reglsteced�toaseJmpr6 s mtCoetnefa(HICK /d z cj U
lie 7/G6 Rq{uumion Nuattier
10C Company Name ur I IIC R Name -
', .•—✓ P Jte.— ,sC%''`�32'�'�JCF .—�xpt�r ion Due
Sisny„rc -Tekphmne
SECTION 6:WORKERS•COMPENSATION INSURANCE AFFIDAVIT(M,G.L c JSL 12SCM)
Workers Competaad.Immwance afrwavd mug tie eoi4leted stmd submined with this application. Failure to provide
this affidavit will resub in the denial of dte Iswinee of the buildbtg permit
Signed Aflidarit Altttchcd7 Yea 13 No
SECTION 7rr OWNER AUTHORIZATION TO BE COMPLETED WHEN"
OWNER'S ACENT'OpR'CONTRAC fOR`APPi 1ES,FOR BUILDING;PERMIT
as Ow eIr of the subjat MWei ty'bneby
authorize `!'{d 5�t2 36v��s f K- to as on'my fralWf,in all matws
relative to work authorized this iltlmg permit application
Si of Owner D -
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLAMTION;
/ {—' �� tJ ti C° as Owns Authorittd-Agent haeliy declare
no
application
that the statements and information on the foregoia Sri
true aitd ecc/�urate,to the best o�f%my knowledge card
behalf. - J (� p r (� �J 6c /il/C
Prim Name- -
Signature Of owner or zed Agem'
Si under the pains and.penallies or .'- .
NOTES:
1. An Owner who obmins building pertnitlo Iij owe F . work or an owner who'hires ere unregistered contractor
(not registered in the Home Improvement Coatrxta f HIC)Program) will have,aaeg to the arbitration
program or guaranty lux under M.G L c 1 J2A:Odter mmpoiwM mfomutton on the,HlC Program and
Comtruction Superyiso►;Laceosteg'(CSL►can&fourod m i80CMR Regulations I IOR6"and I IO:RS,respectively.
i. When substantial work is plammed.provide the infermatmon.below
Total floors area lSq.FL) (tnoluding gorage fieuhed basement/anics decks of patch)
Grog living area(Sq.Ft.) = Habitable Boom count`.
Numbs of fireplaces Number al bfdroomi
Number ofbothraoms NurmiberoPhalObatlmd
Type of his sysletn Number tirdecks/porches
Type of cooling systetn Enclosed Open
). Yowl Project Syuare'Fuoage may be subsntuteJ for hual Project Cost" "
I46N The Commonwealth of Massachusetts
Department oflndushUl Accidents
Office oflnvesligadons
600 Washington Shwt ,
Boston,MA 02111
F r..
' wivtiamassgov/dia ,
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'blv
Name (er�organization/hdividual):��« &Oc,'e 42 i� Cro n/�12QC���
Address:
city/Statel : �S'laLc� 4 , o/2 70 Phone#: /-SDR - ?32--
Are you an emploW Check the appropriatebox: Type of project(rafuired):
I. I am a employer with 4. Lama a gnreral contractor andl
employees(fall and/or part-time).* have hired the sub-coanactors 6 ❑New.Construction
.r~
2 0 I•am a sole Proprietor or partner- listedon the attached sheet Y . . 7• Witemodeling
ship and have no employees These sub-contractors have & [I DramoNon
working for me in any capacity. workers'comp-insmance. 9, 0 Building addition
[No wofers'comp.insurance 5. We are a corporal0n and its T
required] officers have exercised their 10.0 Electrical repairs or additions .
3.❑ I am a homeowner doing all work rightofoxemptiouper MGL 11.0 Phmlbingrepairs or additions
myselL[No workers' comp. a 152,§I(4),and we have no 12,0 Roof
insurance required.]t employees.[No workers' fefla
comp.insurance requued] 13.0 Other
•llnyapplic®t PoetA box err must also fin cot Poe action btbw showing fl *waive' P�c9mfommtiod
tnomaoss*wlm *ddsb isa must
aumd�addw,,e b=tgDwi Band Poen or outside mahaetas mastsvLmita efFt�vR�ca2ing sued _trbmtrncmrs amtc7wdcadstmx must atlarLod®ad&tiosd alxctahowiug 8¢mm�e orl6e wb�mbactasm4gmwo>lQ eomlpPoh9mffirnum..
I am an employer that is providing workers'compensation insurance for my employees, Below isllrepoltcy axd job site
Info�ton
Insurance Company Name:
Policy#or Self-ins. Lie,M. Expiration Date:
Job Site Address:
Attach a copy of the workers'compensation policy declaration page(showing the poky number and expiration date). ,
FMIUM to secaue coverage as required under Section 25A ofMGL c. 152 can lead to Ge imposition ofcriminal penalties of a ' m' "fine up to E1,500.00 and/or on�year imprisonment as well as civil penalties in the fomn of a STOP WOBg OBDIM and a fine
ofnp to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to&e Office of
Investigations of the DIA for insurance coverage verification.
I do hereb unde and penalties of pedury that the information provided above Is true and correct
e: eo
2 / . Date: /
Pbone#:
Offlclal use only. Do not write in this area,to be completed by eityortmm vffldaL
City or Town: PermillUcense#
Issuing Authority(circle one): l .
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other
Contart Persnne _.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compmatioa fPummt to this St2tutr, an or their employees
express or implied,oral or written."vyee is defined as"...every person in the service of another under aY Contract of
hiM
An employer is defined as"an individual,partnership,association,corporation dr other legal
of ffie foregoing engaged in a jointenterprise;and inch ' the 1 1 entity;or any two
or more
remiver or trustee ofan individual,partnership.association or other l l representatives of a deceased e�hloyer,or the
owner of a dwtit emnloyigg employees. However the '
dwelling house ofanother who g out
more than three apartments and who resides therein,or the occupant of the
�1�P�O»s tn do maintenance,constmction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because ofsuch emPloyment be deemed to be an eployer."
MR-chapter 15%§25C:(6)also states that"every state or local licensing a$encyshatl withhold the issuance or
renewal of a license or permit to operate a badness or to constrad buildings m the commonweaith for,
applicantany who has not produced acceptable evidence of compliance with the iasarance COV�gereghhih ed"
Additionally.MQ,chapter 15Z§25C(7)states"Nddler the commonwealth nor any ofits polititarl
enter into any contact for theperf =ct ofpabhc wont�acceptable evidence of SUbdiViSiDaS shall
requirements oftda chapter have been presented to the caatactmgaoity,mA hliance wiffi ffie iasnrame
Applicants:
Please fill cat the workers'WMPCD=6safiidavit completely,by checking the boxes that and,if
necessary,mpph'mb-twjmactor(s) hone apply r ]wmsihtation
Y COmpames glk)or Lnn1e,and bgky Pwbwnumbe bs along with heir aWjbste(s)ymaof .
insurance_ Emoted Lia1't'htyPattaer�ps(ylp)wit►no mezmbets orpartacm,are unt required to tarty workers'compensation ink lfan LLC is LLP does tier than tie .
AAccideats for caomntion of fimu nce�d that thisAlso beaffidavit may be Bubmmod to ffie Depaitmentof lndostrial
be returned to ffietxtyor town that the appha �sure to sign and date the affidavit. The affidavit should
industrialAcddcs• Should you have any questions for 11he pernhitor�se is beihhgrequestod,not�Deptntmuntof
compeasadm policy,please call the rding The law Or ifyou,am requited to obtain a workem,,
self:insurance license mrmbe un DcPa*wnt at the number listed below seif_insured companies should enter their
line.
City or Town Officials
Please be sun that the affidavit is complete and printed 1
D
of the a IY• The Departmeuthas Provided a space at the bottom
ffidavit firryon to fip out m the event he Office oflavesbgations has to contact you
Please be sun to fill in ffie Permidliceuse numberwhich will be used as a reference r�8 applicant
that must submit multiple permidlicewe appliratians iu . In addition,an appneant
8D3't WWY�needOniYsubmitone
Policy mfor>naton(ifnecessary)and harder"Job Site Address"the aPP�tshonli write"all affehrvtf � current
town)•"A copy ofthe affidavit that has been officially stamped or marked by ffie locations in (dw or
hpplie:ant as proofthata valid affidavit is on file for future Pm is or licenses. Ane affidavit bI Provided to the
Year Where a home Owner or citizen is obtaining a license ormtstbe fined out each
e.a do hose or P�tnot elated to any basin commercial vemtare
S permit bun leaves ere,)said peison is NOT rdgnhW to cemplete this
[be Office oflavestigations world hire to thank you in advance for w
please do not hesitate to give us a call yo cooperation and should you have any questions,
Ile rePart_cu.,s address,telephone and fax number
- -
The Gomrnonwealth of Massachusetts
Department of industtial.Accidents
O fflce of Investigations
S ns
600 W ington Street
Boston,MA 02111
f
CITY OF si .&Nl, NL-kSSACHUSETTS
• BUILDING DEP.1Ri-\LMNT
130 WASHNGTON STREET, 310 FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
(O.\tBFRr EY DRISCOLL
MAYOR THoms ST.PmRRS
DIRECTOR OF PUBLIC PROPERTY/BCILDNG COMMISSIONER
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 i 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued-with the coddition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
psi`z ✓L �19 yC-Ul
(name of hauler)
The debris will be disposed of in
Y� J C—
(name of facility)
(address of facility)
signature of permit applicant
/ P7
date
dcbrisalTd•H: