69 MOFFATT RD - BUILDING PERMIT APP 3 The Commonwealth of Massachusetts
�+ Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CNIR SALE�I
�YI Revised Mar 2011
GBuilding Permit Application To Construct, Repair, Renovate Or Demolish a
I One- or Tivo-Family avelling
This Section For Official se Only.
Building Permit Number: Date plied.:;
Building Official(Print Name) Signature Dale
SECTION L" SITE INFORrNIATION "
Ll Property Address: L2 Assessors Map& r Numbers
l.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
s/' " 10�- '
Zoning District Propo ed Use r Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:; PROPERTY OWNERSHIP,
2.1 �^/Ownertof Recor J -2 J
l-2/3Jr/�l �GUE'C G f?�O l.� / ///O��•a7T /Lc.� .�YJ'✓p�'4
Name(Print) City,State,ZIP
�? / of0/�T 9
Ned Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply),
New Construction Cl Existing Building ❑ Owner-Occupied ❑ Repairs(s) W1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': S T�/� O/C/� O G/9 /�Gus271
SECTION 4: ESTINLXTED CONSTRUCTION COSTS-
Item Estimated Costs: Official Use Onl '
Labor and tMaterials y
I Building 1. Building Permit Fee S Indic5te how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ i
❑"Coral Project Cost (Item.6)x multiplier x
3. Plumbin; S 2. Other Fees: S
t Mechanical (lIVAC) S List:
5. Mechanical (Fire 5
Sii : ressinn) Coral:All Fees:S
_ Check No. Check Amount: Qt511 Amount:
total 1'rnject Cost: 3 7 5 � — � ❑ Paid in Full ❑ Outstanding Balance Due: --
-
SECTION 5: CoNSTRuC'rION SERVICES
5.1 Construction Supervisor License(CSL)
Mlle/o �� �- tom _ License Number Expiration Date
Name of CSL I[Older ) oo y GWS
List CSL Type(see below
u/Y/9it/! Type - Description
No. and Street
p� U Unrestricted(Buildings up to 35,000 cu. tt.
Restricted I,@.3 F amil Dwellin
Cityfrown,State, ZIP ;71e onr
Ruofin Covcrin
aNI
Window and Siding
Solid Fuel Burning Appliances
Insulation
"rele hone Email addressDemolition
25.2 egistered Home Improvement Contractor(IIIIIC) %� fj�S — 3/3
A10=f 7 l;h IiO/l9 Aug 0- t;� HIC Registration Number Expiration Dale
f IIC Company Name or FI[C Registrant Name
.t ,4,Lt s T
No. d Street Email address
i7i ov /�i'� CS7�e4� F 76-J7y-a.
City/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers 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? Yes ......� No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize /. C/9/1 <7 /V 4i
to act on my behalf, in all matters relative to work authorized by this building permit a lication.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' 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.
(Tint Owner's or Authorized Agent's Nmne(Electronic 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
(nut registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. [42A. Other important information on the FIIC Program can be found at
%VWW.mass.euv,'oca Information on the Construction Supervisor License can be found at www.mass.eo�ldL
2. When substantial work is planned, provide the information below:
Total floor area(sq. R.) _(including garage, finished basement/attics,decks or porch)
Bros, living area(sq. III -_ Habitable room Count
Number of fireplaces._. __ Number of bedrooms —
__ --
Numberofbathrooms Number ofhalt'baths ----
I'ypc or heating system . _-_ ------ Number of Tacks/parches —_-_--
Il pe of cooling sy;lcin _._ Enclosed— _ Open _
3, 'Ilrtal I'nyeCt tiquare Punt t umy tie i0 tltufed foi -l',,r,d Project C0;t"