13 PARLEE ST - BUILDING INSPECTION The Conuuomvealth of Massachusetts POR
i i Board of Building Regulations :aid Standards Mt'NIL'WA].11 I
Massachusetts State Building Code. 780 CMR. 7 adition til
Building Pei mil AppliC:dio l TO Construct, Repair. Renovate Or Demolish a Rrriwd,h nnu +
One- of FIT(14 unih Du elling /. 7rrr S
']'his Section For Official Use Only
�.. i Date Applied: - O - —_— --_
Building 1 unut Number. PI � / U2 —
liwldinpCumi,i . aai/ InsperturjK1 wlJrragr D:uc
SECTION 1: SITE INFORMA't•ION
1.1 Pro er , koldres S� `_2 :assessors Map & Parcel Numbers ------- -
I.la Is this an accepted street"yes_ no :ALipA'umher PurcdA'weber
1.3 Zoning Information: >( Property Dimensions:
Zoning District 111opoxJ Use Lot Area(sy IU F7uni:ge Uil
1.5 Building Setbacks (f )
Front Yard Side Yards Rear Yazd
Required Provided Required Provided Required Pru�IJcd
1.6 Water Supply: (,I.QL c 40. §54) .7 Flood Zone Information: "C8 Sewage Disposal System:
Zone: _ Outside Flood Zone' Municipal ElOn site Jisposul "It"' ❑
Public ❑ Private❑ Check it yes❑
SECTION 2: PROPERTY OWNERSHIPI
2.1 O �n rt of Record,
hwl �
Name [Prix )
Address for Service:
IV Goo
�A t�MM �
Signature Trlephonz GE LL 9&t-- 1; 7 � l t�+4
SECTION 3: DESCRIPTION OF PROPOSED WORK Z(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied Repans(s) ❑ Alteration(s) ❑ AJditinn ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work2: ' — --
P - - JET
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item 11_aboi and Materials) _
I. liui Wing S av� 1. Building Permit Fee: S 'ID Indicate luiw fee is determined:
`Standard City/1 own Application Fee
Electrical ❑Total Project Cunt' (Item 6) x multiplier <
1. Plumbing S 2. Other Fees: 5
4. Nlechanical (MAC) 15 List: — --
5. Mechanicl (Fire ..
.S Total All Fees: S
)LI) ICSSn)n)
(� Check No. Check Anunmr Ca.h .-A mnune_ -
j o Iu[al Project GuC S C W UJ Puid m Full ❑ Outstanding Balance Due.-- ---
v _
1�
dip 1/1 lion �t+.c�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CS
IA
'\\ Liransa \umbertapir:won
Nuiiii of C'SL- Ifolder -_
Lai>t CSL, l'ype bee f)alorv)
Tv e Uescn anon
\.ldre�>
C Gnrcsuicica :u'❑r i,,00U C' I Ft.i
� R Rcstnacd I.$'_ Fmnih D��rlLne
Signature VIAlaxav- Onle
RC Rroidrnliul Ituoline Cmennt
Telephone A1S Re,Idi1111 a1 A11ndm\ .mdSuhn,
SF Rt NILIcuu.d Sold Fuel Buono: ` Aph ranee Ilhl.11l.a:nl:
D ReSidenual Demohuon
5.2 Registered Ilome Improvement Contractor ILIIC)
TIIC Company Name or IlIC Rceisuanl Name Reglutrauon Nuolher
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insnance affidavit must be completed and submitted with this application. F:ulure to pnwide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attaehed'? 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. If_/,
Signatmc of Ow er 1 61Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, , as Owner or Authorized Agent hereby decJand
that the statements and information on the foregoing application are true and accurate. to the best of my knowled
behalf. "f
Print Name'/y� �7,,,,
Y/l f/fn.uAA / l /O O�
Signature or. uthorized Agent Date
(Signed under the 2ains and penalties o perjury)
NOTES:
An Owner whit obtains a building permit to do his/her own work,or an owner who hires an LIMegisicted contractor
(nut registered in the Hume 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 (CSI_) can be Rnmd in 780 CMR Regulations I IO.R6 and 110.R5. respectl�ely.
r'l' When substantial work is planned, provide the information below:
Total flours area .Sq. Ft.) (including garage, finished basernent/attics. decks or purclu I
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces :Number or hedruorns _
dumber of Mthn o ns Number of hall/baths
vpe-of he:uimg system Number of deckS/ porches
Type of cooling System Enclosed Open _
3. 'Total Project Square Fontage" may be substituted for 'rotai Project Cost-