51-53 WASHINGTON SQUARE NORTH - BUILDING PERMIT APP I'hr ul Massachusetts
Board of Building RCcul.niuns .lnJ S(•tnclaids r( Ilt
Nil NI( II' \1 I I )
l Massachusetts State I3uIIJine. Code. 780l'N1R. 71' edili)nt I
�1
I Building Permit :\I,Plicatietm To ('IntantCt. 12rpulr. R.•ntt,aR• Ur Ih•nx)II,h .t
rnr nr n))4tunilc lhtrlhrll,,
ibis n For Ottic ial t he Only
Buldur: Pennn Num er 1)a[e .\ppheJ:
si_nalure- - ----- ---- _--- -------- - - --- --- - -
BuJJmp Cuumi,,:o Ix.tor of Bu JJ,up, Dale
SECTION I: SITE lNl-ORNI_f30N_____------__-_ -
j 1.1 Properh \ddress: + G_ j 12 \.sensors Map & Parcel Numbers
In jl cce rlej !'� r ,e• _ 1 Nl p\u: d.;r P.u. \wnhcl
�uning InformsYter.: I 1.4 Properly trmrnsiun.: j M.
Zoning t"�intncl Pn)lxneJ (x I Lod .ire.;Isy it)
1.5 Builiding Setbacks (ft)
Front Yard Nile Y"arJs Rear N-aid
RnpureJ PnrvIJeJ Reyuued Pru,:JcJ Reyuu eJ PnWcJ
F--- —�
1.6 Wader Supply: tM G.L c. 40. 454) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone. _ Outside Fhx)J Zone:' }tumor al C On ,lte Ju xaal ,v,tcm ❑
Public ❑ Prl vale❑ Check if ves❑ P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner(of Record:
Name 1 Prl nn Address for service: _----
'�� GM'i-Q�-CSC
S:enalun. Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
—�-- --
j [Vew C) ro[ruction ❑ Existing Bwidiag'� Owner-Occupied TRepv (,) \Iter.lh)In(+) ❑ :\JJlu: n
I-Dem:aitron ❑ Accessory Bldg. C Number ut Uni(s- Other ❑ spe, ly
I r riet Description of Proposed Wtrtk-:_
SECTION 4: ESTINIATED CONSTRUCTION COSTS 1
Estimated Guts: Official Use Only
Vern
II-ahor and Nlarenalsl _
I Buddme _--- S 1. Budding Permit Fee' S Indicate h+I,. ire i, JcteunuteJ.
------
❑Standard (-ity/Town Apphcaunt Fee
?. Electrical S ❑"fatal Project Cost' t Item 6) x Intl l h Ill ier _ x
\. Pdumhine S ?. Other Fees: S
1. Mechanical 114V,\CI S ---
5 i N1eChamel (File S -
Mela chv::nl : rI,I,II .AII Fees: 5
Check No ('heck Amuunl
b Futal Project Cost ) 1 ��Q �X'P.uJ In Full ❑ Oul,t.u)Jing 13.II.11tie Ihle.__
s.
SECTION 5: CONSTRL CHON SERN ICES
5.11 Licensed Construction Super%isor (CSI-)
`,jillc
L '--000
R(
lid
I,F lit"ll ".d"! I I.i
5.2 Registered Home Improvement Contractor (111C)
HIC ( "llipalls 's'lic or 111CRII suant Naive
wdro,,
"Jellatule Idellimile
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT i-M.G.L. c. 152. 4 -'5C(6)1
kkorkers Compensation Insurance affidavit must be cl-Mpletedalld ILJhlllltted with this apple atl,,n
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........13k No
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
hereby
as Owner of lhr- property'
v hereby
to ,.l.ork authorized b,, this building permit application.
S-i2tiatureut Owner Date
SECTION 7h: OWNEWOR AUTHORIZED AGENT DECLARATION
N Si'\r, --, as Owner orAuthoii/ed %--en( heichydeLlao:
-I
that the state merits and in fiormat ion on the I,reg0mc application are true and arc ui ate, to the best or my knowledge and
behalf.
Print .Name
Sienature of Owner Tor Authoo/cclAsent Date
(Sigried wider rhe pat is and penalties of perjur)i
NOTES:
I. An Owner who obiams a building permit it,do his/her own work. oranowner who lures an Ljruegi,ici,d c, im-lo,-1
f no( registered in the Home Impro,,ement Contractor (1110 Pro,gram). will i hj%eacce,s to the x himown
program or guaranty fund underM.G.I. c. 14'A Other important information on the HIC Pr,llzi,irn mid
Constli,Mlon Supervisor Licensing WSI-) can be found in 7X0 CMR Regulations I P) RO :ind 1 10 R5, le'lleLloCk
When uh,tantiA work is planned. pioside the infoinnation below.
fatal floors area (Sq. Ft.I including garage. finished ha,emen(Jallies. deck, ,,r Iii:,,h,
Go,,, Ij% ing area iSq Ft H.ihil,ible r, orril I:,,unr
Number ill' bedro,,in,
Nwnhei of h,ifto,,ins Number of hjl: hj!h,
I\pe ,lr heatilly, 1%,Iem Numher -r Icek,, pt-t-he,
-N,tcm
fond Pn,jeci Square 1:t.1 L il-C Ina', he ILI bS(I I tiled I L i I F. (A I'll 11e,t