20 PERKINS ST - BUILDING INSPECTION f w r4"?
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY$ M
Massachusetts State Building Code, 780 C Revised iLlr IR Revised
2011
Building Permit Application To Construct, Repair, Renovate Demolish a
One- or Two-Family Dwelling
Phis Section For Official Ug6Only
Building Permit Number:
Building Official(Print Name) 'Si na re- Dat
SECTION 1: SITE INF
1.1 Property ddress: 1.2 Assessors M & Parcel Numbers
D D �rP�(G( /7e,� S ( _
1.1 a 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 ft) Frontage(11)
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:
Public ❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2:' PROPERTY'OWNERSHIP'-
2.1,POwner ofRecor
K21/
Name Print) City,State,ZIP
0 7g �ac$
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': r f
nn 4 0 A I Q \2 P4U(4 /J l t
SECTION 4: ESTIINIATED CONSTRUCTION COSTS ,
Estimated Costs:
(tem Official Use Only,
Labor and Materials
1, Building S ?J 7 1 Building Permit Fee: S Indicate how fee is determined:
?. Electrical S ❑ Standard City%Town Application Fee
❑ Potat Project Cost? (Item 6)x multiplier x
3. Plumbing S 2 Other Fees:
1. 'vlechanical (IIVAC) $
3. Mechanical (Fire
Suppression) Total All Fees: S
�7 Check No. Check Amount: Cash ,\mount.
G. Total Project Cost S o / S 0 Paid in Full 0 Outstanding Balancz Due: __
r' 'e
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supe�rvissor License(CSL) Ile �9
License Number C Expiration Date
Nam of CSL Mulder Y—
�., '! List CSL Type(see below)
No. at—mid Street Type - Description
J �/� l U Unrestricted Buildings u to 35,000 cu. ft.)5C✓l P/1'1 ' ` CA U 7 R Restricted M2 Family Dwelling
Cityrrown, State, ZIP LL Masonry
R Roofing Covering
Window and Sidin>
Solid Fuel Burning Appliances
1 Insulation
relz hone Email address I Demolition
5.�.�[2a stered Home Improvement Contractor(HIC) � -0 6 /2 L�
t ,Pl V & �( (n ¢ MC Registration Number Erpir tion ate
Compnr apCorl[ICR• tstrantName
N . d reet ( i Email address
6 c,, �� olY7e �7�q �3S)OU
City/Town,State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L, c. 152. § 25C(6))
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'
[, 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 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
co arced in this application�is/true and accurate to the best of my knowledge and understanding.
9 '(M1 / 0—
I'rin[Owner's or Autlwrita{:\gent's Name(Elcctt'onic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the H[C Program can be found at
w%vw.massjgov:%oca Information on the Construction Supervisor License can be found at www. MISS.1roA,rtIL
2. When substantial work is planned, provide the information below:
Total floor area(s(I. ft.) _(including garage, finished basement/attics, decks or porch)
Gross living area (sq. ft.)— _ Habitable room count
Number of fireplaces_- Numberot'bedrooms _ ----
Number ofbathroonts Number of half/baths _
Type or he system __ Number of decks/ porches _-----_ --
l'ype of cooling systun __ _ Enclosed__-- -- Open
3. `'Ibtal Project Squ:n'e Footage" may be substitutcd for"T(,t:tl Project Cost" __ _