3D NIMITZ WAY - BUILDING INSPECTION The Conunonsealth of Massa(huseus -- —
t Board of Building Regulations and St ind;uds It )It
r. .. �
M1tassuc huset(s State Building Code, 7511 ('MR, 7"' editk,° I sl
h Building Permit Application To Construct. Repair. Renosate Or Dcmohi ll a R, nr J l u ,n
v 0/le- ur Tito-Vamilr lhrrl/ifig t
1
This Section For Official Use Only
Building Permit Nt ec Date Applied: Sd/WM25� _.--._—__---_.. -y
Signmure: — ��-'�G -------- - - - --- - -- -
Budding Cuinmi,ainied In,peaur ul BuilJing' Dane
SECTION I: SITE: INFOR:YIA HON —
1.1 Propertt :Address: 1.2 :Yssessurs Slap .k Parcel Number
;11a Swnher P:urel Xmnher
I.to Is ihti an accepted ,tip t'. yes nu P• __ - _—__ I
1.3 Z•,^;r"x Inf„rinaLion: 1.4 Pro1wrty Dimensioas:
Zoning seta FrnteniJ _ :. f_. Fruit io
Front Yard Side Wards Peat YurJ
1.5 Haila.rg Setbacks tit' _
—
Reu imJ PruviJed Rcyuurd Provided NeywrcJ Pn�i iJeJ
— y
--I
I
� 1.6 Water Supply: (M G I_c 40. §54) !.7 Flood Zone Information: 1.8 Sewage Disposal System:
-- Zone: _ Outside Flood Zone' M1hmici al ❑ On site Jis xrcal s ,icm ❑ l
Puhl[C42-� Private❑ Check if yes❑ p' I Y —�
SECTION 2: PROPERTY OWNERSHIP' j
2.1 Owner'of Record:
lJ.9�C'Li P,9G '1')ee NIM iTE7- (Am
Naw, i Pnnil Address for Service.
Signa;urc Telcli untTi e—
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Cuns(!;action ❑ Existing Building ❑ Owner-Occupied Repairs(s) _ Alteration(s) O i\Uditi,,n ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units__ Other ❑ Specify. ___--
Briet Description tit Proposed Work-. __ --
SECTION 4: ESTIMATED CONSTRUCTION COSTS
W
stimated Costs:(L i'r:and Materials) OFPcial Use Only
ing $ :,)fnng Permit Fee: $ Indicate how teei, Jeler nuned:
d City/Town Application Fee
ical $ roject Cost' (Item 6) x multiplier ting $ Fees: $
nical (FIVAC) $nical (Fire ,�ion) Fees: sr✓W . S?9C•heck :\mount Z� ('.t,h :\n ,umProject Cost: S �j)/�) Full ❑Out,t:u,Jing B;d:mce Dar:__.
SECTION 5: CONSTRUC'TION SERVICES _� J
5 1 enscd Construction Supervisor (CSI.) — --
T,i'C _CAI MN _ r� G N� Llicnsc \unlh.r Il pl r.wnn U.ur
Nance of CSI- IIuIJer
p0 �OY O�y Lmt CSL 'I\pe I,ie heluw l
\JJrc _ y7/(�fp I Deli rt nlun — ..
1. l'nn•su'lilrJ I up to 15.lN10 Cu. hi
R Ri Hrti lid &' f.umh Dw el l I tie
S lgnauu NI Nl:tsonn Onf.
_ -L5 7
_.—L! — % / � RC Ri>I do nu al R uu I n c('I I�i I I n`
Dili Phone __
SF Hi.IJnu1.J .ti�ihJ Purl ISul ninu \ ,.inr In.l_1Il u"11 v.
D Hi aJin1i.11 Urinalwan ____._1 .,
5.2 Registered Home Improvement Contractor (HIC) i
HIC C.mgrmy Name or HIC Re istrant Name Reguu'auom Number
y _
Address —. .—
F.ynraG,m U;tle
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. F;ulure to pru�IJe
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
I
1 _ as Owner of the subject property hereby
authorize to act on my behalf. in all matters
i
relative to w,nk authorized by this building permit application.
Si nature of Owner Dale _—_d
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1. _ - -� _, as Owner or Authorized Agent hereby Jecl aro
that the stateme s information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name —
Signature of Owner or Authorized Agent Date U
(Si med under the alns and penalties of edu .)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or ;m owner who hires an unregistered aonrra,loll
(nut registered in the Hume Improvement Contractor(HIC) Programl, will not have access to the ,hitialiAm
program or guaranty fund under M.G.L. c. 142A. Other important intoimanon on the HIC Progr in and
Construction Supervisor Licensing WSL)can be ti,und in 780 CNIR Regulations 110.R6 and 110 1?5, respect(
When suhs(antial work is planned, provide the information below:
To[al floors area(Sq. Ft.) (including garage. finished hasemenUatttes, decks it pnreho
Gross living area iSq. Ft.) Habitable room count
Number tit fireplaces Number of hedrooms
I Number of h,uhownis Number of halt/baths
fcpe of healing system _ Number tit Jeeks/ p,arches
Type cif'oolmg sutem Ln:InscJ
3 Total Project Square Footage• may be substituted fir 'fatal Project Cost" _.J