12 PHILLIPS ST - BUILDING INSPECTION GK 21C7L4 $ i2 �
The Commonwealth of MassachusettsAa ��
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or DemoOne-or Avo-Farnily Dwellingrn
This Section For.Official Use Onl4�Building Permit Number: Date Applied: Z<Dailding 011icial(Print N.'une). Stgnature �
SECTION 1:SITE INFORtNIATJON' <
to Proper d ass: Jssessors Map di '
Parcel Numbers1I�ltps s�
1.la Is this an accepted street9 yes noN anber Parcel Number
1.} 'Zoning Information: Property Dimensions:
Zoning District - Proposed Use - rea(sy R) Frontage(11) .-
1.5 Building Setbacks(R)
Front Yard - Side Yards Rear Yard
ReyairteJ Provided -Required -- Provided. Required Provided
1.6 Wnter Supply:{M.G.L c.d0,§Sd) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal O.On site disposal system ❑
Public Private❑ Check if, es❑ - . -
SECTION2: PROPERTYOWNERSLH.104;
2.1 Owners of Air)
� -
t�thme Print ��ff . . City,State,ZIP
/? �/l7��`S �� 3S/-20/--/5/�{
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Iff Alteration($) O Addition ❑
Demolition O Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brie De ription of r osed Wor
Ct G' r .J° IPaB.c
a � o
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials -
1. Building S f C900 I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S /00 0 ❑Total Project Cosh(Item 6)x multiplier x
1. Plumbing s /Dc)p 2' QtherFees: S / `�
a.Mechanical (HVAC) S List: r
5. Mechanical (Fire Total All Fees:3
Stippcession)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0�946 ❑Paid in Full ❑Outstanding Balance Due:
(YI A l I,Eb 1 f 6
4
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Liccnse(CSL) Cl Q 2/ff9 (9g
2 License Number Expiration Date
Name"ofCSLHolder / List CSLType(see below)
Type.- . Description .
r; Nu.and Street U e stri �.
- { U Unrestricted DuilJin u �to 33,000 cu. It.
Orel O� R Restricted 1&2F:unil Dwellin
Ciiyfrown,State,ZIP M imasomy
RC Roofing Covering
WS Window and Siding
/' )'Y1B(Y j.�LRROt/�I,s l� SF Solid Fuel Burning Appliances
IW�371 . C.d f�i 1 Insulation
'Tcle hone Email address D Demolition `
5.2 Registered Hom Ira r/yem j ent Contractor(HIC) � 3
hyy-J'I�Fx'i' f���f Prc - HIC Registration Number Expiration Date
HIC Cymp:my Name or fyC Re istr, t NmSeL e ° ZQ e}s ILc
Nu.mW Streeto.. �� Email address
City/Town, State,ZIP o� (o Telephone
SECTION 6:WORKERS'.CONIPENSATION INSURANCE AFFIDAVIT(NILQL c.152.§ 2SC(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 Is§uance of the building permit.
Signed Affidavit Attached? Yes..........O No...........
SECTION 7a:OWNER AUTHORIZAT[ON:TO BE.COMPLETED WHEN)
OWNER'S AGENT OR CONTRALTO 1RAPPLIESIOR BULILDING PERh11T`
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
c) �d Q
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
contained in this application is true im accurate to the best of my knowledge and understanding.
QS� l ei° /� �/1-S
Print Owner's or wrized Ag 's Nano(Electronic Signature) Date
NOTES:
I. 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 no have access to the arbitration
- --
progtam orguaranty fund under M.G.L.c.—Id2A.--Other Important Info"rrnafion do thcNlCProgra—me an be�ot'in�i a -- - - -
Nv%vw mass eov'oca Information on the Construction Supervisor License can be found at www.ntas�
2. When substantial work is planned, provide the information below:
Total fluor 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 half/baths
Type of heating system Number of decks/porches
Type orcooling system Enclosed Open
.1. "Total Project Square Footage"may be substituted fur"rotal Project Cost"