7 PAUL AVE - BUILDING INSPECTION c�sah��'25 IZc-c,�i b35�t8�
The Commonwealth of Massachusetts li'� CITY OF
Board of Building Regulations and Standa 'WWAEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application.To Construct,Repair,RenovJfflt?rjVfn"shp 1: 54
One-or Tlvo-Family Dwelling
This Section For Official Use Onl
r Building Pormit,Nitmtier: Date Applied:
"Building Oflicial O'rint Name) Signature -
SECTION 1:SI1 E INFORMATION
1.1 Ppp aar s: 1.2 Assessors Map&Parcel Numbers
T;F" 1.12 Is this an accepted street?yes_ no_ Map Nurnber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(fl)
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❑ Cbeck ifyes❑ _
SECTIONit PROPERTYOWNERSD7P1
2.1 er�ofRiecord;-
i 2�- �`ct��✓U �T' �J l v r t
Namy _ Ci Stat ZIP
No.and Street Telephone Email Address
SECTION 3e DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Constmction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1.Building $ 1 Suckling Permit Fee:$ lnd#cate how fee is determined-
❑Standard Cityi7own Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $
Lisa: Gl
5.Mechanical (Five $ Total All Fees:$.
S ssion
T Check No. Cheek Amount Cash Amount:
6.Total Project Cost: $ 1��CJ� ❑Pad in Fall ❑outstanding Balance Ilue
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License,(CSL)
License Number Expiration Date
Name of CSL Holder
1a " fi , ; i;, 1 u j List CSL Type(see below)
No.and Street
'Type .Description
U I Unrestricted(Buildings up to 35,000 cu.ft.
R I Restricted 1&2 Family Dwelling
City/Tom,State,ZIP M I Masonry
RC I Roofing Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/own, State,ZIP Telephone
SECTION 6:WORKERS,COMPENSATIOIN D URANCE AFN' AVIT(ALG.L c.152.g 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted withthis application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........O
SECTION 7a:OWNER AUTAORIZATIONTO BE C6NWLETED WHEN
OWNER'S A N'T OR CONTRACTOR APPLIES FOR RNG PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 76:OWNER'OR AUTHORIZED AGENT DECLARATION
By a tering my name below,I Fest er the pains and penalties of perjury that all of the information
co ed�s ap ca n' ecc a to at of my knowledge and understanding.
t Owner's or Auth d is Nam lectromc Sr ature) Date
t1. 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 can be found at
�itivw.mass.eov.%oca It
on the Construction Supervisor License can be found at wµ�a.mass gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
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