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BP-51660 Permit No. BP- 51660 Project Location: 3 GOLDFINCH DR Commonwealth of Massachusetts TOWN OF DARTMOUTH M P#: 3296.00 006 400 Slocum Road,Dartmouth,MA 02747 Lot: 0002 Phone:(508)910-1820• Fax:(508)910-1838 Sublot: 0082 BUILDING PERMIT Project ory#. TO INSTALL J-2008001 84 FIELD INSPECTION Fee:Cost: $750000 Const.Class: Contractor: License.• Phone#: Use Group: R4 Lot Size(sq.ft.) 104.00 Zoning: SRB Engineer: License: Phone#: New Const.: N/A Alt.Const.: N/A Applicant: Phone#: Ceiling: ALEXANDRE L FERNANDES 508-995-3928 Walls: OWNER: Floor: FERNANDES ALEXANDRE L Glazing: DATE ISSUED: /3 4e47 ��n TO PERFORM THE FOLLOWING WORK: O�u��� J �S Pellet stove DATE TIME TYPE OF INSPECTION&REMARKS INITIAL /2-20-67 3zr (2/cn - . Y-P- x --- 0/is VA 1111171111MIIIIIIMIll Cn Permit No. BP-51660 BUILDING PERMIT CxIStE._ 3296.00 , " Comtnoaweaitth of Massachusetts 1LIa 0066 tOWN:OEDARTMOUTH Lot« 0002 400 Slocum Road,Dartmouth,MA 02747 Sub-Lot : 0082 Phone:(500)910a18W ! (508)919-1838 Category: ; .. TO INSTALL _Project# co2008 I.3.84 PERMISSION IS HEREBY GRANTED TO: , Est.Cost: $2566 00 gee:- $700, Contractor: � , ; Phone#. ,. .Co st..Class: y 5 Ilse Group: R4 Engineer: ,Cr .tens Phone# oC' (sq ft.) 3.64 A � Zoning SUS-t Applicant cz ..- Phone#: Nett Const,: N/A ALEXANDREd.FERNA tDES % '`441� 508 495-3920_ gAlt Const: N/A ` "; OWNER FERNANDESL ANDREL ' 6 t 3:w 'vP Date Typed: 12 17tZ007 wd� DATE ISSUED: .,u /J/3i/r/r TO PERFORM THE FOLLOWING WORK: Pellet stove Project ocaltlion: 3 GOLDFINCH DR Approved/Issued By: o lLW )f f DAVID W MATTOS,LOCAL BUILDING IN PECTOR LLL@QQ Z I I G ENFORCEMENT OFFICER Al work shall comply with 780 CMR 6'u Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK,FINAL INSPECTION IS REQUIRED. THIS PERMIT WILL EXPIRE PER 780 CMR 111.8(NOT MORE THAN 3 EXTENSIONS WILL BE GRANTED)OR ON ISSUANCE OF A REGULAR OCCUPANCY PERMIT. I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this Building/Zoning Permit Signature of Owner/Agent:/".. �i7 at 9��zc of 4 "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)r Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing - Wiring Water Service#: Footings: Underground: Oil: Underground: Service: Foundation: Rough: Smoke: Rough: Rough: Sewer Service#: Rough Frame: Insulation: Final: Final: Final: Cross Connection Final: Final: Treasury: Board of Health E-911 Additional Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed onthe white"Required Inspections"document provided with the issuance of the building permit POST CART}SG IT IS VISIBLE FROM THE STREET � TOWN OF DARTMOUTH BUILDING RECEIPTS I` I \� jf, 1 COLLECTOR'S OFFICEy Name,fir' .j =7`"-„ % y �la._.�...,1J Property -._7.'-1',r,• I`!—r�..-/ — - Date: J./ / y / >, f t / // Owner; // ! Job Location: / ) ! / `' / i '' rJ + _ White Copy-Collector's Office j f} Yellow Copy-Customer's Receipt Plot %/i�V, Lot �i 1 or Pink Copy-File Copy Green Copy._-Building Department Phone: _ . N Description General Ledger#'s Ref.# Amount License&Permits-Building 01000-44105 4 \_ \ J -„- ) _., License&Permits-Building Misc. 01000-44105 JIsI (� E License&Permits-Electrical 01000-44106': - \ I License&Permits-Plumbing&Gas 01000-44107 9, 't Other Department Revenue 01000-42420 ^'_i n This is not a Permit or License for Building,Plumbing or Gas ved By: I 0 SPECIAL PERMIT(Per 780 CMR 111.13) S25.00 APPLICATION FEE IS NON DE-FUNDABLE & NON-TRANSFERABLE c _ ` �,: 4�t= DATE RECEIVED - S OUTH;M1��. /� �r�U.. DARTMOUTH BUILDING DEPARTMENT n77T f°i{ ,�i 400 Slocum Road, P.O. Box 79399 `,v. _�a c Dartmouth, MA 02747 -� n-r f LI tv. II: S I ° , Phone: 508-910-1820 Fax: 508-910-1838 ~`6'� www.town.dartmouth.ma.us _ APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY . - - . ' RECEIVED BY BUILDING PERMIT NUMBE4 DA. SENT FOR REVIEW jV DATE ISSUED a ISSUE SIGNATU 1- " - ` DATE/ ` ' b-' - $"the „ tri ♦ .,i TSN,'rs „z;,-.� f8 h� M g �' v i e. Zomn District.' S 'a Proposed Use ` i " Zone B .0 A U V Aquifer Zone THE FOLLOWING AGENCIES SHOULD BE NOTIFIED U Board of -IJ Board'of, U Cons ^'�U Demo : E1.DPW " ' LI Dec ,4, ❑Energy Report Appeals k *Health Commission ' � Affidavit h a Card Sent , Cut Off r Ez Follow up ❑Fire iiUGas U Planning U Sewer Card ❑Water Card El Zoning ❑Other �`- Chief ;Cut Off„ `BoardCutOff --e..Cut Off ;`- '._*REQUIRES INSPECTOR'S REVIEW;BEFORETHE ISSUANCE,OEA PERMIT.v .. . ri E({PARTMM�ENTAL APPROVAL . `Zoning Review: Signature: */ t) Date: 1/43/0? Energy Report: Signature: Date: - Fire Chief: Signature: Date: Ott'Board of Health: Signature: J - Date: Conservation Commission: Signature: Date: Other: Signature: ) ) Date: - Brief description of work being performed: /2/ _ / :.;F - " ,SECTIONS-SITE INFORMATION •12', . 1.1 Property Address:3 C'a t,-.A F II L/C K .1" R- 1.2 Assessors Map&Lot Number: VVVV Nearest Cross Street: --SO/I!U e 1iZC'� f< Map (.4 Lot ji - I Subdivision Name: 1.3 Historical District ❑Yes 0 No Total Land Area Sq. Feet: Has application been submitted to the Historic Commission? / ❑Yes 0 No Date: t1.4 Water Supply(MGL+c4)s54): / Sewage Disposal Syste ❑ Municipal nvate Well b 0 Municipal WOn Site Disposal System 0 CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT ' RESIDENTIAL SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT - 2.1 Owner Record: /12 EXA,Vt Ker L a PER AM i bcs 3 Goi-rrtNeH n : 503-9`ls_39)t8 Name(print) Contact Address Phone Number 2.2 Authorized Agent: Name(print) Contact Address Phone Number SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: License Number: Address:0Expiration Date: LU Signature: Telephone: 2 3.2 Registered Home Improvement Contractor: Not Applicable❑ LLI (_) Are you a Home Improvement Contractor subject to(780 CMR-6)? 0 Yes 0 No —1 If No, go to the next section! LI. Are you darning exemption from the requirements? 0 Yes 0 No D If Yes,submit the required affidavit! >' Company Name: Registration Number(if none, state"none"): Z D Address: Signature: Telephone: Expiration Date: 3.3 For Residential Remodel Work Only PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration, One Ashburton Place-Room 1301, Boston, MA 02108, 617-727-8598. ❑ I am a Homeowner performing all the work myself. Owners Name(print): 0,9L EX/Q/03kE Z_ re—R,1244✓DCS 4_ Signature: . ll_ ,j,24,9 c i qa� �� By signing the above,the homeowner nowledges that there will be no e5ginity to the Guaranty Fund Date: /A — /V 07 3.4 Homeowner Exemption-One&Two Family Only FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 109.1.1 Licensing of Construction Supervisors: Except for those structures governed by cony udicn Control in Secton 116 0,elective July 1,1982,no individual shall be engaged in directly supervising persons engaged in construction,reconstruction,alteration,repel-,removal a'demolition involving the structural elements of buildings or structures,unless he or she is licensed in accordance with the rules and regulations promulgated by fie BBRS entitled Rules and Regulations for Licensing Construction Supervisors. Exception: Any Homeowner performing work for which a Building Permit is required shall be ecempt tun le groirisicris of this section;provides that if a Homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. For the purposes of this section only,a"Homeowner is defined as follows: Person(s)who owns a parcel cif land on Sidi hefshe resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use aMru farm structures.res. A person who constructs more than one home in a two-year period shall not be considered a Homeowner. \ If you are applying under this section sign below: O Signature:• l'l yw(z X Your signature carries certain responsibilities,including but not necessarily limited to,general liability I NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constructic Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) - "` ' < SECTION 4,WORKER'S COMPENSATION INSURANCE AFFIDAVIT(MGL c 152§25) " Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: El Yes ❑ No r: " .SECTION 5'-DESCRIPTION OF PROPOSED WOW('(Check all applicable)` =/'' " " - ❑Deck CI Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace &Woodstove/Pellet Stove ❑New Construction' 0 Accessory Bldg. ❑Roofing/Siding ❑Other (Energy report required) (Shed/Garage) (Specify below) J ,❑Addition 0 Replacement window/door 0 Demolition (Energy report required) No.of windows Doors_ (Specify below) "if new construction, please complete the following: Single Family: No.of Bedrooms No.of Baths Two Family: No of Bedrooms Unit 1 No.of Baths Unit 1 No of Bedrooms Unit 2 No.of Baths Unit 2 ❑Furnace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑HVAC(combined unit) primary fuel,natural gas,propane,electricity,other ❑Air conditioning-(separate unit) ❑None of the above to be provided ❑Hot Water: Gas Electric Fuel Oil Other Description of pro osed o k: --(7.4 , t,iyi .:}i i 7(fac C'fl-7 -C__ At/ //f/742 Yitt-i SECTION.6,=ESTIMATED CONSTRUCTION COST ` r ,�x,,; 1. Buildin ` $ 5oQ., Item Eostimatedtai Cost($)to be completed by permit.--.- 2. Electrical / 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1 +2+3+4) SECTION.TA OWNER AUTHORIZATION ' . ` (to be completed when owner's agentor contractor applies for building permit)-c." 1"" 'tft' (Please Print) I' , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date -' ' SECTION 7B'-OWNERJAUTHORIZED AGENT DECLARATION ;; 1 I, , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. artira z. v��ro /c;.? - Py 07 Signature of Owner/Authorized Agent Date SECTION 8-INSPECTOR'S REVIEW/COMMENTS ' 1. Date plan reviewed: 2. DENIED(see project review worksheet): Date: 3. HOLD Reason: Date: _ 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: // il ({/ Inspectors Signature: •, ✓` " W a Date: / / / 7 s' " SECTION 9'--APPLICANTNOTIFICATION ' ' ; ' "'' Applicant informed of above: Date: C r.47/b7 Time: 3" 5 Clerk; Comments: (a„ze,i srszc ,//lis Fe✓vra—.e ,t 17wr.--,J°" °- Lce , ;; SECTION 10 F OFFICE/INSPECTOR'S NOTES� - ' ` , ' c.'i t. ' '.I p� Less Application Fee:$25.00 7�.G a Remaining Balance: $ —_ Total Permit Fee:$ 7(�t/ 0 0 Other$Amount}� $ 7 TOTAL FEE: f,p`�rm C Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. Permit Issued to: T,Y C C !i / ,,,S c c V te SECTION 11;-ADDITIONAL COMMENTS/SKETCHES ,v ,< !, , ; •o.. ,' rite_-- srcvi 7-C, 00 ct/i n n 4'y -'=_ e.,- "1` 7/ i }fkri A L/' z2c-.;aPA LI I CB 1200 Pellet Stove CUEID E/RE B. Clearances to Combustibles (UL and ULC) r , ,c .c ;h� „asofa,A L. Minimum Alcove Height 44 1117 A C- Minimum Alcove Width 40-1/2 1029 11 Maximum Alcove Depth 36 915 Minimum Alcove Side Wall 6 152 o I % Top of Unit to Combustibles 12-1/2 318 �� B \___ / A WARNING fiii ,t- • 4 -�f Y Y.A;' �t, l i;:}4T4 Fe Risk. a ��,. � � � Comply with all minimum clearances to f Y ay `.'c a - 3 ^ �,e _w: ,,, , vim. combustibles as specified. Ell pi Back Wall to Appliance 2 51 1 En Side Wall to Appliance 6 152 Failure to comply may cause house fire. ri Walls to Appliance 2 51 NOTE: • Illustrations reflect typical installations and are FOR DESIGN PURPOSES ONLY. • Illustrations/diagrams are not drawn to scale. • Actual installation may vary due to individual design Installations with: preference. 3 to 3 inch Top Vent Adapter and 3 to 6 inch Offset Adapter Kit De F G / ---CR 1. 1 ri �% E c ® G 5 4 y I4;S rs i `f 3r 5r0h.,.11 tCY-A IEI A.9 i�)Fz , i fJ51 Veyit ( � 1�'Ff..+b D Back Wall to Flue Pipe 3 76 © Side Wall to Top 6 152 © Back Wall to Appliance 7.5 191 ®//��- `,; f0,1.- Irr= IlytSr „liy 1 F_L laii id r, Yi: ^,' r ILE y a®PI li Walls to Appliance 2 51 -- • • ___ A m m =" C� 'O S S (n (n m O.m 1 = 0 m. N » 0o N o N o A 9 c m 0 .0 cn m 9 m CO- _ 3 o- m m o< m D O a -- a m 3 o = r° n c m v m ci 77 CD v 0 m o. 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O m 0 l0_ 0 a m C0 CO m 0 0 3 0 • 0 m CD d a� 0 3 = 3 s 3 a v 0 ca. 3 m n F a v D'o = m 3. m = d CrFIT ■ m w Q m-do ail o� v 3 'zn m m w o- CO 2 Doi m cG y m o- a N 0 ® 3 0(ii 3 0 o a < v �' obi m o Ic 91 �. .m- e d m m -va a -4 o 'I a T rime O v m m m 3 :P a = m v v 3- 3 N d m - o �o x 3 m v a A d `<O" o -.-. 0 -I O _O O 0- a C 00 O O d)_O _ x m 0 y- = 3. 2 a v=i -o m rn °' o x o m Q v 'o y on . Cr d j O - 0--O. tD = 0 CD C 0. O = m C) d N N-.0 ^ d O c 0 0 - v d O 0 d fJco v = d �1 a o pnj C (D N N 6'0 O = o_ d 0 3 3 a O m ? a ncDD v �D o CO v mati I-c -s I n m D n m Z A Z O - T. 0 all / T CiZT al 01 IWS A m *oxz L ix_ m 0� V • 0 SPECIAL PERMIT(Per 780 CIVIR 111.13) $25.00 APPLICATION FEE IS NON RE-FUNDABLE it NON-TEIA_NSFEFIABLE , „....„-n!!...., DATE RECEIVED 71540-14tn44,-r DARTMOUTH BUILDING DEPARTMENT , ' . .-y.--,,,,..°,-/1.,-,., .,,,,,,,n- frflf,', "Fit 400 Slocum Road' P 0 Box 79399 ' . IC 1St ' xi " • ',.v --Mlitt-±: 4"; Dartmouth, MA 02747 - - :,--- , il tv li• cl \° '-i--- s•-' Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING 74,m-trattnttsp,,,t ,:m,Av 2 ay,i ztA:ti-tis;sE-atbNtitijtftWaakLotttitoLYN1Sy-v,Z: ti S ane0:24t-taaTEM43, r. :VP::*.1-Zt-C'e:'':.'.-c7:.;AtaoY-f T.,.kiEWjk4 w RirfrvkL-:„RVStq-Lhh,.*AISV:ittaz;;,_rir.::MaSknitpswstkpeootrosg„-eiP-A:s ri,,,„. ezty:tg: t,,,..a.:-e,a ,,'.:,,w:rn.!c.A.st..4 ,r,:),X0,41t:tv'i, „''''4=441-0,1•11S- v-*el,k::.• Fit. pw, WO :7-,Azstwrp,, :rj-fkgMsdritcktik itYile1AMOFS:tsitir:;-;:4 4"-7; , ,4-fr:±att,...4-±fte,STEWSVE52-rauunig;21;:--.P:-;*Mt .--,f,-,,:Avals.rzygwwmsew.aw.hatiiikt,..eo-P,:4:54:_ TflgyafiR,Maik‘IfflitflaWat,.,7,„ ,,„',.';',r,,,,a7tpeimizqtt, '*O.W.ift-IN1,21'.4.?,KIV 'ti:.4",0421).NWlitif.,,,,_4fW4.WE,,tSlt'AgarrefirataLgiaitaFeitilt,sen AtiSqlesw;t,slikiktimEtkawarratinwasti,wraalia::; :7.gtettAikiEfraTs_Waitat,p74,75:1;i:tf at-1100,40?:44ittleiCS#S4nk:,--Te*:::ecte:00:72:::,,a: :1,,,Siarl SteSeentrefat .:2.c-LzA-rifa;t.;W-ZE:ISM.egM-4nsa.-t:-+A--aw#::-npaeotirb',;4':-7;:-tit A4oliffir4iNoWide4M-33WNRV:07?-,006getiVeningalfaciantrer#fria-iarg4ilefOrieMazIAFet:Saai t.N.O.Arra, ',.;':.Zr!tr(h$1,41•41:444.4wi.,„•''0.4s;aa-4,Thkr-t;4,4*,4-y-.&A-4cc,'t-1-- ION! wtV:f :‘..e,,,aitt"";naPrr';'4 t".'24 ,kl'Hrtatt' -a,',-T.,,,,I .,Mtr, •;-' ;',::C''','.7 ,05-C:''e.'('t'W-1-'J.f• gt:,'n'Cr-Vrtt1:*:-`,,kfr-t?;,,-Alt,:,.,-n; r Pt.,#,- ,--;,',-,Miz_arr:445,,_F,‘4,,,,ttbl,-„,_:4,,,, -,Iva:1yr_, 114K,}0-e, 11-4g,whowtoc.,,e4E10eigs:31-putpsa..opFicestmea--3- a,k,i4-;144,TIVOSIPRIMOtY'agqi,I;WAStrk,910aakf. 10,„,s,,k,01: , 4, -a, .4.4,444._ i .::.c ,E,10.3,,,Acmtv: Ii._ thareittifesonitydeeth4,,isia:t„?. , otif t -,-..., tetnfek;---*,,' -- , atidear,ii6$1aeli00 k4-.4---)-..''.. --747--rff,;-.11--16.-- 7-2= ,; (•:ft's-rhr-c-..,,e7e.:„”itat,,.--,-,-,,,kteS,±T. - .. k,-_ ty..-,,.,, .-----,-- -.!ti.).4.,E, p.(q,,§irz:c43,4,4c .;„, ,,,t;:.r.,;.,:,qqamis..19paif,!igif.k„ avjts:it,,,,,visegick,SentA_I---- - .&,,f.Put-Pfit.47 724;13.•rIzEpAgyflp1- ; t-74.1.MPSIP4 1,44'nenfirti'lr. 13 ,- "4-', iiTljat,--, 0gs..,..tr,ifre:i.:4,-Tht: ;13;,:sps:in, •,!4--,,,,Ari:F,:s.annirw.w24::‘,LTISe i',1 Card,--,; :::-0WaterfektF,Ra , ; ,Zoning? -, ,,w1 0,044,-zEtffr, P -,bfitgi-V:"'V'Vt-Vs0h':ejit"oien5f.tatlWaii""zt'itll't6iiS-: s--ta -44-415ffr'S.,74th-e- ,,z,,,A.ert-vtz-,i4T-77,50Pe.=::;-,q ,::,:wnttztv.: MMI4VOSM4S4Watirtra-te4E--41,..ii,;z, nf7.ftrei:MTiniii*-FIECIO INSPECTOR'Sit<ES . . izERJ.;'IEW,FA:,--7,.:7E4SOSIPAL'.t. ',OF;::-",Ptatit:- ,-*&i:&4•.:.-.Wi-,24:13-,p,,.5flt;,:= 3.-VVi.iTMY ',-4070:Aktimtatto*PPIt09.A.0:4771WZialtBAtitcaY5W.P%-i-,---taill:734. 4:':• Zoning Review: Signature: Date: - Energy Report: Signature: Date: , Fire Chief. Signature: 2 i Date: N Board of Health: Signature: ; 4A-6c Date: la74/6 -7 Conservation Commission: Signature:/ Date: Other: Signature: Date: , Brief description of work being performed: j , C , I ;le::: ;; ;',.);:%:.-----;:i,-:-\''-',ra-;: .E::,;;:=7-i- ,:,:c---:':-,'-'.:-::: .:,:-.{,"11',-BECTIOW.t-..?:$17,rgiNFORmATiotst:Itilt, , {95gksrls-f-=:,:ftty,,-,5-1--,7.7,,: / 1.1 Property Address:-3 ea tmt) FlivC t4 .b.A., 1.2 Assessors Map&Lot Number: ,e) Nearest Cross Street: --SP 04.16. C.-%lAt\N., bit- Map (.7, 1 Lot 631 - y.)- . Subdivision Name: 1.3 Historical District 0 Yes 0 No Total Land Area Sq. Feet: FILE COPY Has application been submitted to the Historic Commission? Dyes 0 No Date: .4 Water Supply(MGL city s54): 0 Municipal reP rivate Well i .5 Sewage Disposal Sy Styr. i• 0 Municipal ekeOn Site Disposal System 1 , El CONSTRUCTION PLANS El SITE PLAN El ENERGY REPORT , ; ---- L., c.',, ', .4 r' R.tv r...› glg),,o'' ea g s 2 z ri - z:-, -3 z - z z›, g. gi iii i.: e s' 2-,rio ii g,0 _ ei-itteem ie e0- . ,:, - . , , z i- 0.iii, . z t/2 0 tv: t'-4 4 4 n ty tn co '' i-3 .-' CZ ig 0 ,. •H P1 C 0 Z tC •• ,,,r C n 3 n r .?, ,_q z tg - 5:-,.c„ 5 MI L.) 2. '.: .71 P'< i 0 r ::t--';.! '' 4 0 cn ct 4 0 mi .,:,i ., -0 cid -- 00x .1 4 e ., - e > 0-c:) 1-••• > ri t$ . 121 b , 0 0 ‘n 1'1 01 . ---• 2 iri :: s 4 Z t d ..... 2 11 8 -4 '-i Z a ril rt t- a r c ..... ,1 • , „. cr, ...e .-• r21 C R.,,.. . ; ,,-; 1/4...,1 it -3 n ce, N 7, = .. z < 3...c c, 0 f... b Z d '-"' Ca d ..., x n fl •• -;,1- . 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Q i' "d 3 i 7 9 0. n + $ 0.i " et ° o a x A {r CIn 9 s z r y . 5 :5 Y r A a eea0om p W ° N nn44t [3aO ,Kr'A Oma Z�+a c[ e -. ,s... o o .n ma < o o x c n n a m n n m 6 o c , "?7 o o c,ozn n O�'d_ -0 3 a y m o. p a o lKv W o O o m e na a -01 y W p.r'i.+ry -. o f ti c c OOo Om ' n o. 0= o r n o" nn 7O : m i maaavoi Amy e q 00 $ $ 3 =" Y ln� a _ o.Zw O n< ^ �'.. N r rs C 3 .. y › 3 n' 7, tl O N W N it N tio- k 3 3.. �' ni R W o r a 0 A W p i �1 A.�. T :. y a td b t‘a ootri c c o �ao�-mo "-o c C�C,.: o •ow a ' O " y b< hO r N0AJ0 a J O V N tn j •Nnchi Ca J Vy — J 1I P O W D QON^ O n CS OO N N V Ca W I CoO �A W to A N V .>' �P.n ol \ 'b N o 0 C De �N .... Tl pe VO N A J to W Ln 0 n C J O r y r O A^• I N IN J N r W CO yt e ' W O N W 0 J V _-1 O "4 m o xi n tt n u v; a N) e. r R A J m -a r J N n o m y @ '9 �' m 0 V O O NI L, = N 7 CD O O C a m A A = an to C e. a m lls a C A A A O N O T. r p J ili bl � I SECTION tt=INSPECT.OWS RNEW/CONIMENTS , 1. Date plan reviewed: 2. DENIED (see project review worksheet): Date: 3. HOLD Reason: Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: Inspector's Signature: Date: H3..kr>?-43.€"£"'. .n d.5.e t p 'r Y Yg i5 v}x to #'*:`` N*l�'M''' a .a't x ¢r y W -a` ��+.. � .-,_» t�,.=.x.'.LSECT.ION 9 APf�LIG`ANT�.NO:'[fFlC1�TIt7A{,:s ._ �a� _.. r° . _ . ,-�5c�rr�. : Applicant informed of above: Date: Time: Clerk: Comments: ti- v . +2:1i,k ,i„Ltsy'`119i"?t ',.*t u..A Sri ,AYpg�+' tCrTION_ TO.I�SAKO NSPEGT41 la tar*.` `'r ti'x'r3',k'aCa:_:, i..RA -`N "'.i",,S Less Application Fee:$25.00 Remaining Balancer $ Total Permit Fee:$ . Other$Amount$ TOTAL FEE: Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. Permit Issued to: F; ,.a—f .,. i >'a*`ia;ttON7i1g4:ADDIT1oKW OMNIEN /tfCET a. 4 t ..MS^ nSzgl ueiaWl lir FILE copy The Commonwealth of Massachusetts w= Department of Industrial Accidents I lei=I Office of Investigations to = o y 600 Washington Street Boston, MA 02111 �� w ww massgov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):j9l.&Xi/it i'C L.. f Er-AlJ4tt/N i=5 Address: a 6oL.6 five k .DR. City/State/Zip:Ai, bAR Y Mov i k-1 yin B0771/7hone #: L5oS 9575-T yja2 S Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 1 ' • ❑ 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 10.0 Electrical repairs or additions required.] officers have exercised their 3.M 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.❑ Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.0 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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. it: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: /�ana 2. 1�itn 7,7. 3 Date: .42 —/V -07 Phone#: Official use only. Do not write in this area,to be completed by city or town official FILE Y 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#: 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 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 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 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 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 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. 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 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-MASSAFE Fax#617-727-7749 Revised 5-26-05 www,mass.govldia