193 1-2 NORTH ST - BUILDING INSPECTION (3) qT3
_\ The ('ununonwealth of Massachusetts
t - Board of Building Regululio \I
ns and Standards Fult
1.
•'Y I NI( IP.11.111 Massachusetts Slate Building Code. 7SU ('MR. 7°i edition
NI.
Building Permit .Application To CunsuucL Repair. Renucate Ur Demolish :t R, hrnw,,,
0ite- or Tit o-hautrily Dnc•llin,q 't'It'x
This Section For Official Use Only
Building Permit Number: Date applied: ------- _
Signature: -----------
13m1d+rig Cunun isvunerA li ,pector of 13uddmgs Dais
SECTION 1: SITE INFORMATION .
1.1 Property JJretis: L 1.2 Assessors Map R Parcel Numbers
I.L, Is this:m accepted street'. ycs_ nu Map Nuniher Pafcel ,Numher
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use [..of Arc:,(sq tU Frunw_e (it)
1.5 Building Setbacks (ft)
j Front Yard Side Y:ads Rear Y;od
Required Provided Requited Provided Requited 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 disposals sign ❑
Public ❑ Private❑ Check it yes❑ I I Y
SECTION 2: PROPERTY OWNERSFIIPt
2.1 Ownert of Record- �6/P
Name i Print) Address for Service:
Signature Telephone --
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) .Alieration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Pry used Work': S
ro O �J
SECTION J: ESTINIATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building ,7J I. Building Permit Fee: `5 Indicate how fee is determined: j
❑ Standard City/fown Application Fee
2. Electrical S ❑Total Project Costa (Item 6) x multiplier x
+. Plumbing 5 2. Other Fees: .S
1. :Mechanical IHVAC) 5 List: ---
i. Mechanical tFire 5 _ ----
Sut resnion) Fotal All Fees: Is
Check No. Check .-Amount: Cash amount -
6. Total Project Cost: 5 0 Paid in Full 0 Outstanding Balance Doc
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Constntetion Supervisor (CSI.)
License Number 1'spir:111 Data
V:unc ul CSI—_- (taller
Li>t CSL'fvpe (see helow) _
\ddres> l\- e Descn nton
- L L'nnsumedn(vio 15.Uf10Cup Ft.;
-- R Restricted I.@2 F:unite D\kelhng
Sign;mua %I Nhuonry Only
RC Renidenuul RuoGng Co�eonu
fe1cphune \\'S Res I&II((al Windom .uW SiJuL
SF Relldemn.11 Solid Fud Burning A t)'rater lu.(.Jlaljlml •'
D Readenlcd Demahium
5.2 Registered Ilmue Improvement�'ontrac r 0110
v l Gi»n y
IiIC Company Nam•or HIC Re pis rant Name Regulratiun Number
/� , / �� 07
Address Qt7
e'y�--- �77'// D12 Espuatiun Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (N1.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to prosidc
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 to act on my behalf. in all maulers
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1. , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application ate true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Dale
(Signed under the pains and penalties ofperjury)
NOTES:
I. 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 (CSI_) can be tintnd in 780 CN1R Regulations 110.R(i and I Ill.R5. respecticcly.
'. When substantial work is planned, provide the information below:
Cotal flours area (Sq. Ft.) (including garage, finished basemenUattics. decks m porch'
Gross living area (Sq. Ft.) liahinahle room count
Nmnber of fireplaces Number of bedrooms
Number of hathruoms Number or hail/b:uhs
Tvpe of heating system Number of decks/
type of cooling system Lncluscd Open _
3. "Total Project Square Footage- may be substituted too "fatal Project Cost"
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