1A PARALLEL ST - BUILDING INSPECTION i
The Commonwealth of Massachusetts
FOR
Board of Building Regulations and Standards ICI
LI'il'L)SE
Massachusetts State Building Cale. 780 CMR. 7,h edition (1SF
W Building Permit Application To Construct. Repair. Renovate Or Demolish a Reeked humwr
One- or Two-Ftonily Dwelling
This Section For Official Use Only
Building Permit Number. Date Applied:
Signature:
a
Building Commissioner/inspector of Bui gs Date
SECTION 1: SITE INFORMATION
1.1 Property Ad�dre" ( / /1 Ze1 1.2 assessors Map & Parcel Numbers
1.la Is this an accepted street'?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage Ili)
1.5 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:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public ❑ Private❑ Check if es❑ P �' Y
SECTION 2: PROPERTY OWNERSHIP[
2.1 Ownef,of Rgco d:
Name(Pei / Address for Service.G/'
7�,s 9d 7
Signature T— Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repeirs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition X Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: �'�� ti• t�
Brief Description of Proposed Work':
hlo 7t le -ice a"
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ I. Building Permit Fee: $moo _ Indicate how fee is determined:
[3 Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Totel Project Cost: $ ❑Paid inFull [3Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Y e T,-J ` %ti 5S P_ License Number Expiration Dale - '+
Name of CSL- Holder List CSL Type(see below)
Type Description
Address U Unrestricted top to 35,000Cu. Ft.)
R Restricted Ilh'_ Family Dwellin
Signature M Masonry Only
RC Residential Rooting Covering
Telephone WS Residential Window and Sidm
SF Residential Solid Fuel Bunn .A lhancc Ina.dlation
D Residential Demolition
5.2 Registered Horne Improvement Contractor (HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. S 2506))
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
1 , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' 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
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 gA 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 110.116 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 halt/baihs
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"