12 PARALLEL ST - BUILDING INSPECTION (2) y.� 1
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7ih edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish-a-. 413-596-2800
One-or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Number: Date A i 1
Signature: 4✓/
Building Commis er/Inspecto of Building Date
_ SECTION 1: E INFORMATION
1.1 P ty Address: 1.2 Assessors Map& Parcel Numbers
r2 e S{ .
I.1 Is this an accepted street"yes__ no Map Number . Parcel Number
: 3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use I Lot Area(sq tl) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required _ Provided Required Provided Required Provided
4: 1
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Q— Private❑ Zone: _ Outside Flood Zone? Municipal 12lfrnsite disposal system ❑
Check if yes[]
2 1elan;a Owner'of R Ya
SECTION 2: PROPERTY OWNERSHIP'
ecy�,�d: p
etzR P2ra/lei/ Sf. __
'Name(Pr Address for Service:
( fA_ _-
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New ConsWction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) O Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':__'-plae e- 2 W.0 c,) r1-4-0C
ll.enl ;n k_e - AaC �e 44li✓7CLocr.`r _ ---
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ I. Building Permit Fee: $ . Indicate how fee is determined:
2.Electrical g ❑Standard City/Town Application Fee
❑Total Project Cest'(item 6)x multiplier x
4. Mechanical
Plumbing S 2. Other Fees: $ �n C 1 / ��
4. Mechanical (HVAC) $ List f�. h �r 7r
5. Mechanical (Fire $
Su ression) Total All Fees: $
/ Check No._Check Amount: Cash Amount:
/7
6.Total Project Cost: $ GOO 11 Paid in Full 0 Outstanding Balance Due:
r ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
* 4/LZ%f U�J tG/L
yka,4-e "2e Aaofn _ License Number Expiration Date
Name of CSL-Holder
X f . 5't48 List CSL Type(see below)
— Type I Description
Addres U I Unrestricted(up to 35,000 Cu.Ft.
'/' R Restricted I&2 Family Dwelling
Signature rR
Mason Only
Residential Roofing Covering
Telephone Residential Window and SidinResidential Solid Fuel Bumin A liance Installation
Residential Demolition
5.2 Registered Home Improvemert, Centractor(HIC)
HIC Compan} Name or HiC Regkirant Name Registration Number
Addr cs
�t 97�
._.1[O1 _ _fit 7ip� �7 Z%O I.F Zt Expiration Date
Signature v ��,y��/�Tct:+phone
SECTION 6:WORYEFS' Cf:;1iI%;N'1ATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Cori:ensatoa Ir, urar. s affidavit mist he completed and submitted with this application. ',7aihtre to provide
this affidavit will result in uu-denial of t;!e Issuat of the building permit.
S;gned Affidavit Attached? Yc� . ... .. ;7 No...........❑
SECTION 7a: OWNER AUT::J^S:'.i1't.^"IC±SL COMPLETED WHEN
OWNER'S AGENT OR CONTR.4C'If;:: f_ OR BUILDING PERMIT
I,_ _ v1 -1•U�L 0 a _, as Owner of die subject property hereby
to act on my behalf,in all makers
relative to work authorized i,v annisation.
--ibneiwe of Owner _ Date
SEC I-i:J(r 74.r1wNF;;' (,R A UTHORIZED AGENT DECLARATION
I, U Cz�. /e_ _ /✓JQ r �i-ex 14n) ,as Owner or Authorized Agent hereby declare
that Coe staterne;ots and inlormaftcxt on the fa.egoing appiicat;=a.c true and accurate, to the best of my knowledge and
behalf.
I CLl C. ,a— ------- . ..
Print ame -
— '
Si ,at re of Owner er A cur; Date
(Signed under the pains
I. An Owner who obtains a building permit to do hishrr own work,or an owner who hires an unregistered contractor
(not registered in the Home Imprm cmtmt l_'onz actor(HIC)Program),will not have access to the arbitration
program or guaranty fund tinder M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11026 and I IO.RS, respectively.
2. When Substantial week is planted,provide the information below
Total floors area(Sq. Ft.) _ .:(inclu;;ing garage,finished basement/atiics,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"may be substituted for"Total Project Cost"