105 NORTH ST - BUILDING INSPECTION f '
The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards MUNICIPALITY
i� Massachusetts State Building Code. 780 CMR, 7 1hedition USE
W Building Permit Application To Construct, Repair. Renovate Or Demolish a Ret ised Jamm,.e
or Two-Fanti/v Dwelling /, 21x)3
Th s Section For Official Use Only
EBuEnglitm r: Date Applied:Signature: Commissioner/ Inspecwr of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: J 1.2 Assessors Map & Parcel Numbers I
/dS =f°1{�__J-T '
Ma Number Parcel Number
1.la is this an accepted street'?yes_ no_ P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sq fl) Frontage Ili)
1.5 Building Setbacks(Pt)
Front Yard Side Yards Rear Yard
Required Pmvtded Required Provided Required Provided
1.6 Water Supply: IM.G.L c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if Xes0
SECTION 2: PROPERTY OWNERSHIP[
2.1 ,Jawneirt of R ord: ,tLr ��.�1� ��/ /l f'T• Q�_ ��p�
bevC ( o n
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work*:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building $ �� I. Building Permit Fee: $ Indicate how fee is determined:
Standard City/Town Application Fee
2. Electrical $ A�l 14LO ❑Total Project Cost'(Item 6) x multiplier x
3. Plumbing $ �. 2. Other Fees: $
4. Mechanical (HVAC) $ s orn List:
S. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No.26_A. Check Amount: Cash Amount:
6. Total Project Cost: $I PP�I APaid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.11 Licensed Construction Supervisor(CSL) & y 7F6 /O
License Number E. pir ran Date
Name of CSL- Holder
frf. SG, �`� last CSL Type(see below)
%ddress Type Description
U I Unrestricted l up to 35.000 Cu. Fr)
St R tRestricted 1&2 FamilyDaellin
Masonry Only.
RC Residential Roofing Covering.
Telephone + �,} \^i`','Y WS ResiJemiul Window and Siding'
SF Residential Solid Fuel Bunune A ilianre In,[Alatiun
D •sidenfial Demolition
5. a Itpeed Ho Im rove nit ontr ct HICa
H C �.t�y a or HI>~. Jtegistr t N S Regi ration Number
J 17 e / a
AJdrrss l0
7 7 Expy rtiun bate
tgnatu 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 7c OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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: OWNER[ OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoi application are true and accurate, to the best of my knowledge and
behalf.
Print N
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780'CMR Regulations 110.116 and 110.115, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics.decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system :¢.j Number of decks/porches
Type of cowling system ;Enclosed Open
3. 'Total Project Square Footage" may be substituted for"Total Project Cost' h,
1.