152 NORTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts
IBoard of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7`"edition R O EM ise✓a
Building Permit Application To Construct,Repair, Renovate Or Demolish a f 1, W08
One-or Two-Family Dwelling
MisSectton For'OffictalUse;Only
Building Permit Numbe : Date Appligdt
Signature:
Buildm Comihiasioned In's_ctor ofBto dmgs a " Date:_` -
SECTION 1 SITE3NF,O1tMAT10N,
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
LI a'Is th�accepted street?yes no I Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use 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.-Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
_ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'`
2.1 nerro ecord: r -
N e(P i t) / Address for Service:
eignorturd Telephone
SECTION 3:DESCRIPTIO,N OF PROPOSED WORK''(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ AI[eration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': "
S
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: OfScial-Use Onl
Labor and Materials y
1.Building $ I. Building Permit Fee;,$ 'Indicate how fee is determined:
2.Electrical $ ❑Standard;CityfioWn Application-Fee
❑Total-Project Cost'(Item 6)-multiplier x
3.Plumbing $ 2 Other Fees $ J
EE
4.Mechanical (HVAC) $ Ltst 9C!/A 1
5.Mechanical (Fire �=
Suppression) $ Total.All Fees. $
6.Total Project Cost: $ / Check No. Check Amount: Cash Amount:
(� U 13 Paid in Full ❑Outstanding Balance Due:
SECTIOIvjS CONSTRUCTION 3ERYIGES
5.1 Licensed Construction Supervisor(CSL) / —
M (L, a e L License Number Expiration Date +
p
Name of CSL-Holder - '
_ h "c P P7,t I.J UU - I 1 SG-Q¢/k` List CSL Type(see below) y r
Address n n 1 T ' "D'escri lion
- U Unrestricted u a ily Dwelling Cu.Ft.
R Restricted 1&2 Famil
Signature � i-1 M MasonryOnly
�— 2 S' 7 13 RC Residential Roofing Covering
Telephone WS- Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re isteir-A H e I rprovement Contraet or(HIC) %� S_�
LL-- C_
HIC Co Name or MC Reg t nt me Registration Number
Address T, y '+' __ 5 7k,7(/`f EA3 Expiration Date
SignaturLy%/1�'^lA .Y / Telephone
SECTION 6 WORICERS'COMPENSATION INSURANCE AFFIDAVIT.(M,GL..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 AUTHORIZATIONgT BE;CQMPLET,EDWHEN'
OWNER'S AGENT OR CONTRACTOR APPLIESi 0IR'13UILDING-PERMIT,
1, g v Cl S q as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to wUauorized by this building p mit application.� a C a Ile
Si aturAfOwher Date -
SECTION 7b:OWNERr.�.OR1AIITHORIZED,-AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Al / r [,/ie
Print Name
Signature of Owner or Authorized Agem - Date
Si ned,under the pains and penalties ofperjury)
NOTES: r .
�,_. _
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.R5,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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"