2 LOONEY AVE - BUILDING INSPECTION (2) $ 25 d1b Cr Z
'rhe Commonwealth of massaClItAt� CTIOML SERVI ES
Board of Building Regulations and Standards BALEM
WMassachusetts State Building Code, 7801MIlPR 32 A— vised,bIar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling _
( This Section For Official Use Only
Building Permit Number: Date Applied,
-OTildin OOdlcial(Print Name). Signature,
SECTION t:SITE:INFORNIATION'
1.1 Property Address: 1.2 Assessors Alap&Parcel Numbers
� GOiti+�� sr/�d
IK
1 I this an acce ted street9 yes no Map Number Parcel Number
ing Infortnntion: 1.4 Property Dimensions:
istrict ProposedUse - Lol Area(sy R) Frontage(R)ldingSetbacks(R)
Front Yard . .. - Side Yards RearYardired ProvidedReyuired Provided- RequiredProvided
er Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Private O - Zone: _ Outside Flood Zone? Municipal O On site disposal system 13
Cheekif esD
SECTION 2: .PROPERTYOWNERSHIP!
ert of Record::-lZ.At/ .e�(•re�;C.Lrt nt) City,State,ZIP .
2 Lon y A✓ 61 7- --4.. z
- No.and StrcM - Telephone - Email Addnsg
SECTION 3:.DESCRIPTION OF PROPOSED WORKS(check A that apply)
New Construction O Existing Building❑ Owner•Occupied O Repairs(s) Alterotion(s) 3 Addition ❑
Demolitionr. Accessory Bldg.0 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=:
`ram s ACVW-rs G"' .rtJ t' >iYo Gtc stT r tAAr`t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itan - Estimated Costs: - Official Use Only
Labor and Materials)
I. Building S 3 a 00 1. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S 2?Pther Fees: S
4.Mechanical (HVi\C) S - List: _
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount Cash Aiwunt:
6.Tutal Project Cust: S 38pp,e"�' ❑Paid in Full ❑Outstanding Balance Due:
hn q,t_t=n S 14
1jelv59—
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
Avg
Type'. - �-� - .,,�':� - � Description .
No.and Street -
y,2�/ ; U Unrestricted(Buildings 3' ea. tt.
R Restricted 1&2 FamilDnAj Grz ,.J i�
City/1•own,State,ZIP M Masonry
RC Roofin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
,✓1C�JJ""J `xo5Pe !T°( ^ I InsulWion
Telephone Email address x D Demolition
5.2 Registered Home Improvement Contractor(HIC) % ZlI%/� ( � • J
5CC4> n}�r �luk to_150 J HIC Registration Number Expiration Date
11 lf L ny Ni v L, RAtJ,i strunt Name �y��s�rJSeny.`jCs7fP-�-
rthisaffidavit
reet Email address 6WAIc'e w
jit{o9 C 2+F�� �3i 1"�s�r-�n State ZIP Tele hone
CTION 6.WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L a 152. 2$C(6))Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
will result in the denial of the Wuance of the building permit.
ffidavit Attached? Yes.......... No........... O
SECTION 7a.OWNER AUTHORIZATION.TO BE COMPLETED WHEN'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERART
I,as Owner of the subject property,hereby authorize -<C." 07yTN
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
jli�ke.j,,) GFf��k.�L� $/GiL/Zr16•
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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 hires an unregistered contractor
_(not registered in the Home Impr veTent Contractor{HIC)Program),will no have access to the arbitration
program orguaranty fund under 1MLG.L.c. Id -.Other impor-a n-i-forr aoo -
— - -
www mass eov:'oca theHICProgramcanbefai�3f-
Information on the Construction Supervisor License can be round at+vww.mass.eov,'dns
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) N (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
rype of heating system Number of decks/porches
Type of cooling system Enclosed Open
]. "Taal Project Syuaro Foaa��'may be subsfiuned I'or"Total Project Cost"
The Commonwealth ofmassachusells
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
wivorkers'Compensation Insurance Affidavit:Buitders/Contractors/Electricians/Ptumbers.
TO BE FILED WITH TBE PERMITTING AUTHORITY.
Applicant Information WI Please Print Legibly
Name(Business`/Organizationtlndividual): 5co yr— 17�4,atdG"AiSo .+✓
Address: ! 6 3 ' 1Ap iL A Lf-E--
City/State/Zip:_4,,Z(.-(AJ6TOAii A 07-r76Phone#: &Y'14St-ASSI
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑I am a employer with employees(fill and/orpart-time).• 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in
MY capacity.[No worker'"comp,msorm,, required.] g- E]Remodeling
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required]1 9. [e Dernolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on m property. 10 O Building addition
ensure drat all cofactors either have worker'co Y P PertY. I will
proprietors with no employees mpensation insurance m are sole 11.Q Electrical repairs Or additions
5.�1 am a general contractor and I have h and the subcomrctm listed on the attached sheet. 12.Q Plumbing repairs or additions
These sub-contractors have employees and have worker comp,insuranmt 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised theirright no a§I(4),and we ha of ex 14.Q Other -
152, ve to Per MGL C.
rap yeas.[No worker'comp..insurance
re mquiqui red]
'Any applicant that checks box#1 must also fill our the section below showing their workers'compensation policy information.
t Homeowner who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContracmrs that check this box must attached an additional ahem showing the name of the sub-counectms and state whether or not those entities have
employees. If the sub=contractors have employees,they most provide their wurker'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.M 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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certffy untie M d ies ofperjury that the information provided above is true and correct
Suture -1 Date
Phone
O
fficial only. Do not write in this area,to be completed by city or town ofciaL
n: Permit/License#
ority(circle one):
ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
on' Phone#:
j4aU LQ 0 tie-V—' 5
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or'other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter,I52,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants `
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents
idents for confirmationof insurance coverage. Also be sure to signand date the affidavit. The affidavit should
Acc
be returned to the city or town that the application for the permit or license is being requested,not the Department of
din the law or if you are required to obtain a workers'
Industrial Accidents. Should you have any questions regarding Y q
compensation policy,please call the Department at the number listed below. Self-insured compa
nies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or rnarkedby the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future perrruts or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Deparhnent of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02 1 1 4-20 1`7
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia _.
I y
CITY OF SALEA AWSAaASE7
BUUDMDEPAR7lMT
'120 WAgMCMSVW,3EDFLOOR
IkL(978)745.9595.
1:1M�YDAFSOM FAx(978)740 9846
MAYOR 7MMUSTYMME
Construction Debris Disposal Arl*l it
(required for ali demolition and,.reno" loin work)
In'accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debi
and the'provisions of.MGL coo, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111,S 150A:
The debris wiI Ue transported by
a
A ee92t.� 7itJfGi.�J5or�J
(name of hauler)
The-debris will be disposed of in;
._.. .
i
(name of facility)
fs
SD �Q�Nr T "Cifalg'
(address of facility)
ignature of applicant
Date