8 OBER ST - BUILDING INSPECTION TICS-It4 - 13ao g523 t�2
�LN The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEIVED
Massachusetts State Building Code, 780 ECTIONAL SER ICE
Building Permit Application To Construct, Repair,Renoval[ 1OrA�¢�ishA 2BRevised
One- or Two-Family Dwelling YY uuvv August 15, 2013
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature: �'9_t'yi
Building C iss r/Inspector of Buildings Date ' '
SECTION 1: SITE INFORMATION
1.1 Property Address: p 1.2 Assessors Map&Parcel Numbers
Lla Isthis an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: --"
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.� 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: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
_77l1M,Ga
Nam�t) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKz(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ElAddition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': t'A de _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials _
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (I VAC) $ List:
5.Mechanical (Fire —
Suppression) $ i Total"All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �QU ; 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I C{t�. e( 5) License Number Expiration Date
Name of CS -Holder
au � t List CSL Type(see below)
Address `t dJ T Descri tion _
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature 29 7 L/�_�� / ' M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
- SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) r✓ 6 �//
HIC Company Name r HIC egis nt Name Registration Number
Address Expiration-Date'
Signature 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 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, /I per/ 4,S 4 i �. as Owner of the subject property hereby
authorize ztf Y. i to act on my behalf,in all matters
relative to work authorized by this building permit application. G
p �L
Sign re of Owner Da!
SECT ERr OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. �-
Print Name f1
L
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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.R6 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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"