69 MOFFATT RD - BUILDING PERMIT APP+ �, - --- I'he C'onununsse;nhh utbl:usa:hu�clts - .
Board of Building Regulations and Standards CI I'Y OF
Massachusetts State Building Code, 780 C NIR
Building Permit Application To Construct, Repair. Renovate Or Demolish a
Core-or rivo-k1 mina Uu ellin.11
This Section For OflScial Use Only
Building Permit Number: Date Applied:
_ VTtZZ
Building Official(Print Mune) I, Sipature me
SECTION I: SITE INFORMATION
I.I Property Address: 1.2 Assessors Slap.it Parcel Number
1.]a Is this an acce ted street?yes no INhipNumhcr Purcel Ntm,ber
1.3 Zoning Informadont 1.4 Property Dimensions:
Lining District lImposed Use Lot Area(sq II) Frontaga III)
1.5 Building Setbacks(R)
Front Yard Side Yanls Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.I.c.40,154) 1.7 Flood Zone information: 1.8 Sewage Disposal System:
Zone: Outside Flood Lune?
I'ubFic❑ private❑ — Check if es0 Municipal❑ On site disposal s)stcm ❑
ReFord:
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of ` �9 �
F.t9�r/l I 'ot/e c cli.'e 6 7 ` /a/ e Tf /e �
N;une(Print) City.Slate.ZIP
6 7r--25r- /re if
No.:md Street refcphuna Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) qJ Alterations) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ .Specily:
Brief Description of Proposed Work': Sy ��/ env-74— 74- ery
SECTION 4: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs:
(Labor and .Materials) Official Use Only
I. Building S p'a�eLU3P
ing Permit Fee: S Indicate how fee is determined:
'. l:'irarical S
ard CitylTussn Application Fee
l Project Cost'(Item O x muhiplier --.x _
1. I'Imnhing S Other Fees: S_ x
J. \Ixhanic,tl ill\ Wl S '•
� � Vcdtanic.tl tFve S I Fces: Su. ( hack :\mount: Gish \nnnmc
n fatal Project Cost: S �`� " n Full ❑l)wstanding BaLulce Doc:
SEC11ONS: CONSI-RUCTIONSERVI('ES
5.1 Construetion Supervisor License(('St.) e-r—O
.. _ ��, 1 icense Number f\piralion Mac\';uncul'l'SI. IIulJcr ...._--- IistC'Sl. 1')pe(saeI'VItm)./ .� - ma's
I>PC Dexriplion
No aidSlreel (I IlnresirmediII'liIdili $'1 Io1S,I1110.u. 11.1
/ vitlilvl /'_ O/93 5_-__. .__ R Re.mricwJ Lr_' I.nnil D,scllinit
Clpil'aan,Slane.L11' — SI %laslm
RC' Rlh,lin Cu\crin
µ'S Window.mJ tiidin
SF Solid Full 'if
1116.\PPIIa .1
1 II»ulutiun
I bona Ilntail address D Demolition
s.2 glittereed�Ilume Improvemeent Contractor(HIC) el
lZ��tOlpir,2iv 01 A/ �e�� IIIC'I(cgibuatiun Number F%Ilirutiun Dum
I IIC CompanL.Namc or I IIC livi; trust Noma
No. arid L•'muil address
City/Town.State ZIP Tmlc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 .........Al- No......,....O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize A /y'
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print O%wer's Naha(Electrunie Signature) Dula
SECTION 7b:OWNERt 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 he best of my knowledge and understanding.
Print oencr'i or:\uthoriM,\gam'+N,ale 1 bleann ie Slymllurel Date
VOTES:
7\nner \\ho obtains a building permit to do his.her own work,uran owner who hiresan unregistered contractor
istered in the Hunle Improvannent Contractor 1 H ICI Program), will nu have access to the arbitration
ur guaranty fund under\1G.L. c. 142.>. Other important information on the HIC Program can be found at
rs. �„ .', I Infornruiun on the Construction Supervisor License can be found atul2. ubstantial work is planned, provide the inf'ur m tion below.rea Isy. It.l 1 including garage, finished bascmenLattics,decks or porch)area 1sy.'11.1 Habitable roust count
I \umber of lircplaccs .... -... . \unlher ul hcJrounu . .
\timbermhathrcoms .. --- \tunbcrof'h;dfl,:lilts
1\pcol'llcatings)slcln . . . . . \umhcr,N'decks, porches
I\pao1'clmlingaslcln I?nA tla,aJ ( cn
I. "l olal Project tiyllllfe I'oolage Ilia\ I+e QIh,t1 uwd for"I.nal Project Cost-