1 OAK ST - BUILDING INSPECTION c ��� �, I'he C'ununontvcahh of,bl:usorhusclU
hoard of l)uilding Regulations and Standards CITY OF
Mass
arhusctls State Building Cute, 79U CMR ti,\LI:\I
ld•ri.,dJ I Lu'11111
Building Permit Application To Construct, Repair. Renovate Or Demolish a'
Otte-or Tuv1-Family Dmelllo.'
This Section For OfficisiI Ont
Building Permit Number: Da Appficd: _
Iluilding 01110al(Print Mum) Silinat rc / Dale
SECTION 1:SITE INFO IATION
I.1 Property Address: 1.2 Ass a � ap,it Parcel Numbers
/ 0.19 K Sv�
Via Is this an accepted street? es no 1XIapNtunI%-r Irurcel Norther
1.3 Zoning Information: 1.4 Property Dimensions:
/uningDistrict 11n,powdUs6 Lot Area(sq III Frontage(11)
1.3 Building Setbacks(R)
Frunt Yurd Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6\Vat r Supply:(M.G.I.c.40.154) 1.7 Flood Zone Informallon- 1.8 Sewage Disposal System:
Ihtblic Private O Zona: _ Outside Flood O Zone? Municipal❑ On site disposals)stem ❑
Check if cs
SECTION1 PROPERTY OWNERSHIP'
1�1'Owner�of�ayr�£S
Nmna(PrinU City.State,ZIP
9;�S-33? ZK7
Nu.and Ssreet relephune Email Address
SECTION J: DESCRIPTION OF PROPOSED 1VORKs(check all that apply)
NewConstruction Existing Building O Owner-Occupied ❑ Repairs(s) 13Afteration(s) C3Addition O
Dent Deolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Spvvq:
Brief Description of Pro osed Work': /rc L7 )(' /o T)Qe/<
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Otliclol Use Only
I Labur,red..\laterialsl
I. Building S eu I. Building Permit Fee: S Indicate how lee is determined:
O Standard CityiTuwn Application Fee
l '. lilrcuical S ❑Total Project Cost (Item 6).x multiplier _. x
1 I'hunhing 5 1 Other Fees: S_ -
J. \IMI.uliC.11 ill\ W) S List:
j \Icc)taniad IFire S ----.-- — -- - - . . .
1u„ressuml rota) \IlFces: S_.-___----
0,�,, ('heck No. ( hcck AmoulIC _ C.uh \m,nml:
n 1'utal I'rnjcct Cn.N: /'(S/y f}2 pw Cn(�
C3 Rut[ in Full ❑UutsnnJing Ilahutce Due:
St.'('[IONS: ('ONS I-RUCTIOINSERVICES
S.1 Cbnstrucliun Supers isur License(CSL) � � � / 3 '
Lou lic¢n,e Nwnh.r I'\plr:ui,u l);tc
N,uneal'CSLIIuIJcr Ilsll'SLI'�{telscehcluwl._
1)pe D¢riripliun
No. and Street -- -' . ..—
^�` � --- -' 61970 lI Reirivtcd 1&2 F-Jin usli to ls,l)llll Cu. IL1
R RnlrideJ I lS P.Imil D\wllin
C'itvikmll.Slate./III SI Ma"'11
RC Rmdin Co\erin
N'S 11'inJn\c,mJ Sidin
SF Solid Fucl Ilurning \Ppliances
I Insulation
Tele hone 14nai1 address D Denntliliun
5.2 Registered Ilume Improvement Contractor(HiC)
IIIC Registration Nunlher Fvp' iruliun Ume
I IICC'ompan) Nmnv or I IIC Registrant Name
No, ;old Sweet Email address
Ci /Town,Slate ZIP Tele hunt
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 23C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atlidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........O No
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as owner of the subject property, hereby authorise
to act on my behalf, in all marten relative to work authorized by this building permit application.
Print Uwnc(s Nunia(Electronic Signalun:) Data
SECTION 7b:OWN ERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
costa' d i ation is true and accurate to the best army knowledge and understanding.
Print l) \l r`s or,%whurired,\gent's Nunle II(Ied..... Signamlm) Daly
NoTES:
I. .\n Owner svhu obtains a building permit to do his her own work,or an owner who hires an unregistered cumrecwr
(nut registered in the Hunte Impruvtment Contractor HIC) Program).will1 have access to the arbitration
program ur guaruu) fund under M.G.L. c. 141A, Other important information an the HIC Program can be lilund at
„o,\ m,,, ';„ ,', I information on the Construction Supers isor License can be found at
2. \\hen substantial lurk is phumed.provide the infur naliun below'
ratan (lour area 1 sq. Il.l ---— —I including garage. finished bostntcnl attics,decks or Porch)
Gross lis ing area I sq. Il.n Habitable room count
�wnher of IirePlaccs Numher of hedrnnms
Gnnhct of halhnwnls -- �unlber ui doll haths
1')pc of h¢eting i),letll ..\nnlhet of Jecki porches
i ll+
I\Pe nl Coollllg i\,tell) I?Ilch„211 ( ell
2 .,toial Pr,ieet Squaw Ioolacc IIIII\ he ,uh,lit ucJ Il,r 'rot.tl 'mjccl C'o,t”
t
v '
CITY OF S.UZNf, LtiLjs&kCH(,'SETTS
t3t.arloiG 0EP.m.mL\T
1 _'0 TURNGTON SrXW, )'*FLOOR
� fLt. �97� 73.959!
K)JBERE Y O LSGOLL FAX 144984
MAMA Mosw St Punas
011=08 OP PL et.tc PROPIiTY/acMnmc CO3L%IfssfOV E!<
Conitruction Debrij Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section I 11.1
Debris, and the provisions of MGL o 40, 9 54;
Building Permit At is issued with the condition that the debris resulting from
111 work shall be disposed or in a properly licensed waste disposal racility as defined by&IGL c
I 1 I, S 1 JOA.
The debris will be transported by:(n4me ul'hauler)
The debris will be disposed or in :
(1270 o-djly)
I Jdarao ar n"I„y)
u rtJnue 1permitrpphcJnf
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