13 PARLEE ST - BUILDING INSPECTION (4) Tbiq -, �
/73
The Commonwealth of Massachusetts
11 I � Board of Building Regulations and Standards CITY OF
,\E Massachusetts State Building Code, 780 CMR SALENI
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised,tkar 2011
One-or Ttvo-Family Dwelling
This Section For ORicial Use Only
Building Permit Number:
On pplied:
BuilJing 0117cial(Print N�une). Date
SECTION 1:SITE INFORNIATION
1.1 Pr�ertyA�{�e��S�/'j/ -
1.2 Assessors Nlap& Parcel Numbers
I.I a Is this an accepted street?yes no hfap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Proposed Us�--
Lot Area(sy It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards
Provided Re
Require) Provide) Rear Yard
Required aired
9 Provided
1.6 Water Supply:(M.O.L c.40,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
2. Owners of R rd• SECTION2: PROPERTY OWNERSHIP'
e•
..Nytme(PnnQIZ
-lc - // 11 0,- 9>C)
City,State,ZIP �Qj
Nu.mrJ Street 90 -
Telephone L•mail AJJresg
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units
Brit f Description of P oposed Work': Other ❑ Specify:
SECTION a: ESTIbIATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Nlaterials Official Use Only
I. Building ,g I. Building permit Fee;$ Indicate how Fee is determined:
2. Electrical S �Q ❑Standard City/Town Application Fee
3. Plumbing ❑Total Project Cost"(Item 6)x multiplier x
Off' 2. Other Fees: S
d. Nfcchonic;tl (pIVAC) S List:
5. Mechanical (Fire
Su ression) S Total All Fees:S
6. Total Project Cost: S C Check No._Check Amount: Cash Amount:—
Fall p Outstanding B;tl:mce Due:
kt) Ap
O/9.6 0
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor '�ense(CSL) Ex nation Date
//4!C64 f 1 / License Number P
Name of CSL Mulder f List CSL Type(see below)
T`i r/� ° 'fYPe Description
No—old Sired Unrestricted 13 Farmdin s u el ill 0 cu. It.)
D/ D� R Restricted I&2 Family Dwellin
M Mason
CA/Town,State,ZIP _ tic Roofin Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
7 Email address p Demolition
Tele hone /7/ O y
5.2 j;l t �/
ed H_,," I Sov�uent Contractor(HIE) Hl 'Registration Number Expiration Date
trant ±ime C
IIIC Contgat NamT.P r HICgts /LF` —
SS Email address
No.and SueeL�
Tele hone
Cit /'town,State,ZIP
hIPENSAT[ON INSURANCE AFFIDAVIT(M.G.I»c. 152.§ 25C(
SECTION 6:WORKERS'CO
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 ..........
SECTION 7a:OWNER AU TIIORIZATION.TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIIE�S FOR/BU_ILDING PERMIT
Las Owner of the subject property,hereby authorize this building permit application.
t9 act on my behalf,in all matters relative r uthorized y () 20(
Date
Print Owner's Nane(Electro c Signat )
SECTION 76:OW t t OR AUTHORIZED AGENT DECLARATION
By entering my n in be w,l hereby attest under the pains and penalties of perjury that all of the information
contained in s' p' ti t ue c . e to the best orm kno`Vledge and understand' g.
Date
Prier Owner's Authorized Agent's Na (Electronic Signauve)
NOTES:
I. An Owner who obtains a building permit to do his/her own word,or) will n it`havetac access toires an ttthe arbitration
registered tractor
(not registered in the Home Improvement Contractor(FIIC) Pro ram),
program
us.'oaroca I fund under tM.G.L.C. 142A.nfo formation r on he Construction hSuperver isor Licertant fnse can be found ormation on the at w N Program,c on Itfound at
?, When substantial work is planned,provide the information garage, finished basement/attics,decks or porch)
(including g g
"total floor area(sq. ft.) Habitable room count
Gross living area(sq. RJ___-------- ,lumber of bedrooms
Number of fireplaces Number of half/baths
;Number of bathrooms Number of decks/porches�—
'rype of heating system�— Enclosed_____—_—.Open
Fype of cooling system
3. 'Total Project Square Footage"may be substituted for"Total Project Cost"