11 LYME ST - BUILDING INSPECTION (2) 2 / l G 52
The Commonwealth of Massachusetts
� Board of Building Regulations and Standards CITY OF
y(t,( Massachusetts State Building Code, 780 CN1R SALRevised�E r1201!
Building Permit Appli cation'ro Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Ap ted: /ram _/0-
Building Olticial(Print Name). Signature- Date
SECTION 1:SITE INFORMATION
1.1 Property Address: / 1.2 Assessors Map&Parcel Numbers
1.1 a is ihis an accepted street?G no Map Number Parcel Number
IA " mling Info • tion: 1.4 Property Dimen ons:
Zoning District Proposed Uri Lot Area(sy tt) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6\Nate/gSupply:(M.G.L c.40,§54) 1.7 Flood Zo Information: 1.8 Sewage D' posal System:
Public L9' Private❑ zone: _ Outside Flood Zge(e? Municipal On site disposal system ❑
Check if yes
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Re,c��QQrd:
�hme(Prii ) City,Slate,ZIP
�O ae/v-P 5789��3647
No.and Street Telephone mui ess
SECTION 3: DESCRIPTION OF PROPOSED WORKi(check II that apply)
New Construction❑ 1 Existing Building Wf Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition LrlAccessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Descrip of taJ 7R,tion
s
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and iNlaterials)
1. Building S Qo ✓ 1. Building Permit Fee:S Indicate how fee is determined:
!D ADO✓ ❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Cost'(Item 6)s multiplier s
3. Plumbing S d OD I_ Other Fees: $
4. Mechanical (1IVAC) S List:
5. \lechmtical (Fire S Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:
(. 'fuCtl Project Cost: S _D DOD / 11 Paid in Full 0 Outstanding Balance Due:
I
SECTIONS: CONSTRUCTIONSERVICES
5.1 Construction Supervisor
SSupervisor License(CSL)
r�o� License N�unSiber/ —Exppiirat�ion Date'
Name of CS Holder
�C 9 ^ List CSL"type(see below)
OJ z ,l w
No.and Street /C Type - Description
r1 U Unrestricted(Buildings u to 35,000 cu. It.)
�N,Ydd O/ �`' R Restricted 1&2 Family Dwelling
Cityfrown,Slate ' l M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
9Zj00 9In A/ . I Insulation
Telephone 6n it a e D Demolition
5.2 Registered
/Home Improvement Contra or(HIC)
OS /C OC ef- EIIC Registration Number Expiration Datof
I11C Con ,my N=egisdant Name ,
MI-j4Street AAAA nn// p� �y a ma'I dd ss
or:c7A&0,6 4 /y!A �l Zed 7 ,5 �Q)2�
City/Town,State, 'rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AF f[DAVIT(MIG.L.c._152.g 25C(6))•
Workers Compensation Insurance affidavit must be completed and submi ed with this application. Failure to provide
this affidavit will result in the denial of the Isivance of the building per t.
Signed Affidavit Attached? Yes .......... ❑ No...........IV
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
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 in wledge and understanding.
Print Ot er's or Authorize Agent's Nan 'lee is Signature) Date
NOTES:
I. 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 NI.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
www.mass.gov"oca Information on the Construction Supervisor License can be found at wtew.mass. ov:!dL
I.—When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basementlattics,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 otheating system Number of decks/porches
Type ofcooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
CITY OF S,\U.EI.1, N'La ss.�CHUSETTS
BUILDING DEPARTMEINT
4 120 WASHINGTON STREET, 3TD FLOOR
° TEL (978) 745-9595
FAx(978) 740-98.46
KiNtBERt FY DRISCOLL
MAYOR Tlicl s ST.PIERRE
sr DIRECTOR OF PUBLIC PROPERTY/Bun.DiNG COJLUISSIONER
orkers' 5Coinpensaeion Insurance Affidavit: Builders!Contractors/Electricians/Plumbers
Applicant information I Please Print Le ibl
NuITIC(Busines. OrganizatioNlndivi(ival): — bi
Address: �y /
Ciiy/State/Zip: .Q� Phone #: !
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 7 am a employer with 4. ❑ 1 am a general contractor and I
6. ❑New construction
ployees(full and/or part-time).* have hired the sub-contractors ,—,,(
v 1 ran a sole proprietor or partner. listed on the attached sheet.: 7. fi24)emodeling
ship and have no employees These subcontractors have 8. jyDenrolition
working for me in any capacity. wcakers'comp. insurance. 9, ❑ Building addition
[No workers* comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their I0.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself. [No workers'sump. C. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.)
•Anv applicant that checks box#1 must also GII out ilia saction tclow showing their workers'compensation policy inhumation.
'I Iomeuwnimi who submit this aff davit indicating ihry are doing all work and then hire outside contractors mini submit a new affidavit indicating such.
=Camirxtors that chcrk this box must atlachad an additiomul sheer showing the name of the subs cntraetors and their worktrs'wrap,policy infomution.
l ran an employer ghat is providing workers'compensation insurance for my employees. Below is the policy mad fob site
informariam
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
'I Job Site Address: - City/State/Zip:
Attaches copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
orup to S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of li
Investigations of the DIA for insurance coverage verification. _
l /do hereby certif corder the pains and hies of perjury that the information provided above is true and correct
phone ii: '✓ ✓ 6
OJJicial use only. Do not write in this area,to be completed by city or town ofJieiat
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
I
l Contact Person: _,„_ Phone#:
CITY OF S.U1 EM, M--1SSACHUSETTS
BI;ILDNG DEPARTNLENT
\ � 130 WASHNGTON STREET, 3' FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KimBERL.EY DRISCOLL
AWOR THo.%w ST.PtERas
DIRECTOR OF PUBLIC PROPERTY/BI U-MG COJLMISSIONER
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 condition 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:
(name ofMulct)
"fhe debris will be disposed of in
(narrij
(address of facility)
sign Lure of permit applic
date
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