11 MAJESTIC AVE - BUILDING INSPECTION The Commpnweulth of Massachusetts
$oard of 8mlding Reguiattans and"Standards
m MUNit IP\1a 11
Massachusetts Swte Hutidmg Code 78tj CMR 7 edition
UJh r•
Hulidi4FermitApphcahon To Constru a tr Renov. R vial knnrmt
One ar,Tx a,F u)tily t1x !l�i�g t 'tN19
Thii Sett nF r ffi i Use
Haeldmg Permit Num pied
( Signature �i
- BmldmgCammisswmd speuoroFBuddmgs IIme
SECTIONI SITEINFORitIATION
Y.Y P operty Address , i 1 Assessors Map�t Parcel Nambers
A.luJSr.thjsanzuTeptcd ;Mrp Mumbei r Panrt Nuadvcr
13 Zaasnglnfarmntton =Y 4 Property Dimensions
'Zoning District Proposed Use - 'tat Area(sgttj Frontage tit)
1$ Butlding 5et6aclts(ft) h
`Front Yard;, # Side Yards Rear Yard-_,
Reyuimd. ` ,:Provided ,Itequtred Provtded 4 •`Requiied�a -:Pmvidcd :;
T 6 Water Supply tM G L o.40 §54j 4.7 Fhiod Zone hifbrmatlon! 1>1 Sewage Dtsposai System
2 v Zone Outside F3ood Zd`ne3 ,+ '•"
Public Ll "�;Pnvute❑ ,i r, Manuipat O--pti site disposal system
- �. . .:Check if yesC7 r
_PRtOPERTY.{SWIVERSHIP; ,
OwrieriotRernrd '
s�{�,•-ftX�.v't�?O�i!� �c.Z�.ct r/, !'r+'"1�:���`F'..f 1"C �'�� �"7i'`lz
N (Pnnt) - - Address forServCce
n
priature ,, s Telephoiu ¢'. < R 'f - "
SEC TOM 3 DESCI2YP CYOFi OF PROPOSED.I9LORK2{cheek ail that apply)
.,;, Ngw Consmecuon t], ,£x}ahng Building i7 ,.Owner Occupied Q Repntrs(s);l3 Alteratian(s),. Addippn,.Ci
'�: Demoitnori r ry' g a ;, -
„❑ ,Accesso�`131d t]• ;Number of Units : ,Other`q Specify"'-��` �� `�'
BriefDCscripiionafProposedWork : DcFif fTyd�x d fr
�`/67¢ 17'rf�L'-. ,fi'G-i.✓,rY1 ys'r.rr" 75' �+"3" dt3S""" '� "f .C7 -C_ r S"ff ' '>
r _ -
' Estimated Costa x"
Izein s {Labor and Matt sj _. OHtict®d`Use Only
t.
1 Buiidsn $ ` y i Bu)Iding Perinit�Fee Uridicnte ha1•e w e:t3 determined
g J
7777
Eiectncnl $ t�j {}�( Standard City/CownApplicapanFee
❑Toud Project Castt(Item 6)x m-777
ulupiter x'
3 PfumPipg
4 Mechanical,(HVAC) $ r..:� rList
5,
Mechanical lore w $ c:
5u ress ff Total Ali_Fees $
ti Total Project Cost ..,i$ `� CheckNo Cheek Arntiunt +'Cash Ami�ant. ` `
` :r. _ „ . _ ,..��,�� _ ," ❑Pn)d m PuB , Q Ouistand�ng Bulunce Due �' - . . � -
7
SECTIONS1.
RVIC
9WOWMON"SO, _ES
7,i
A
tdt?� E ' t liat;,qnsc , um �pimioq
N,
"wi-cs'ET below)
)0,'
script
U - Ajdremrij-,eA,lIi in35.060 Cu.Ft i-
I&I Fifirril I%i,nW
.... -RC' R�-Md"IlaURn"r. o
S 2`R
s C
41 CompanxNamorHIC-RegistNie ' egi I tin
Number',
jk- . -y,i st Expirauun ate
o "
Tel ne
Lire
SECTION'6-.,,WORKikgCOMPENSATION INSURA E N,C 15- 2. P' *dc
ricctu i avatmust' "cq-m"pela" submitted
Morikeirs ampensattlow nsu.fa." -n)v l :
...........
.. .. . ...
dun&
PprM-
Signed
.. .....
— .... o-I
'AffidirvitfAvact y SECT 7a. V ,_r-"_';-_
ION,, 'OV OWNER WHEN
:OM 'FOR BULbi&tTj9RMlT ,,WER'SAGENT-0
77-7=
as Owner
7� t
ION
'
wnz�.T�
r:. fit rizedi-Ageniitt erebyd' Ce
that the statements and in orma d
accurate t tion on the -,an �� cr t
7 he-best of my knowledge an
Pent
-`Signature
t re of.Ovncr& uA igna in
t
Ni t'61djrhtre e -
owheri4hot trasan unregistered cuntfuctizir".
'a'b*
6,jujit _ fi
Tmgravn),�Wtrill jW hdi��,ttk6ess td't e- r itratiOn
iii -
program qr,guaraht�fund under 142A dftan Vin ormatidn.ontt e,I4iC-OrDgTam a—
299�e Cdfis v Li' gfC S
fiiki...to. Supervisor
It 1 7 isor, censin X-10.Fib atui4iI D RS_,
die'. f'
korktis Plainnied;.proVida:2�`;�, -WhadliubstdritidIA in ormation below
.Tntai floors Wren(Sq FL) ...... (inc[id'ng-gl_i iji eiA6iid e�ks,br pireh)-�
j-
F abl
alit rroomcolin
e
N U_M_ Cr i 'fi-m p'avte's
.Number
o fbed too
MS
Ndiicr 0t61mams ofhlb h
jr
'Type of heatingeystem' Number`of kfieksl'porches
Type of t xl
t.oiibtig system
Eric;16 d
Open
-a
Footage substituted far "foia!Proleet Cost
Boston, MA 0-7111
nnvw.mass.-av/dia
Workers' Compensation Insurance Affida«t: Builders/Contractors/Electiicians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): l W !✓f rA4,-Ein iS A-J\\
Address: sly / C/L6i 6'(1— f
City/Mate/Zip: yz� eC S 6
.ore you an employer? Check the appropriate box: Type of project (required):
I am a employer with _ 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2. ❑ I am a sole propr)etor or partner- listed on the attached sbeet I ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
'.kny applicant that checla box#1 muse also fill out The section below showing their workers'compensation policy information:
Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such
Contractom that check this box must attached an additional sheet showing The name of The sub-contncton and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
,rformalion. f
nsurance Company Name: Gl/r%' ,-_7 ;�/ !J
'olicy t or Self-ins. Lic. #: C Expiration Date:
_,b Site Address:I� /79 —Cl L ,�/7/[2 city/state/zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date),
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
oe up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine
C up to $250.00 a day ago nst the v olator. Be advised TY at a copy of Iles statement may be forwarded to the Office of
ivestigations of the DIA for insurance coverage verification.
to hereby certify under the pains and 'nalties ofperjuiy that the information provided above is true and correct
--nature: zzz /JiG r� Date' —7--el
one#:
Official use only. Do not write in this area, to be completed by ciz)r or town official.
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
6. Other
Contact Person: Phone #:
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."
.4n employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing eneaoed in a joint enterprise; and including the legal representatives of a deceased employer, or t]be
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house baying not more than three aparanents 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 dwellin= house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
".GL chapter 152, ;35C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of it 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 ttrith the insurance coverage required."
AdditionaPy, MGL chapter 152, §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 insnTance
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 for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies 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 perntit/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 marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
-year.—Wbere a l one mvneror-citizen-isobtaining-a-license-or-permit-Dot
-related-to-an-} business-or�ommertialy�nture
(i.e, a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFB
Fax # 617-727-7749
:vssed 5-26-05 www.mass.gov/dia