9 PLANTERS ST - BUILDING FOUNDATION TheCommonwealthofMassachusetts MPECTIOYAL `.ER`!CIWOOF
i Board of Building Regulations and Standards SAL,y ur2011
E/M
Massachuset'tsState Building Code, 780CMRIDIS SEA 7�3. ReegU
Building Permit Application To Construct, Repair, Renovate Or Demolis a
One-or Two-Family Dwelling
/ This Section For Official Use Only
` Building Permit Number: Date Appl' d:
1
Building Otticial(Print Name). Signature Date
SECTION 1:SITE INFORMATION'
1.1 Property AXVtYS 1.2 Assessors Map&Parcel Numbers
I.I a Is this an accepted street?yes (_ no Map Number - Parcel Number
1.3 'Coning Information: L4 Property Dimensions: D i
SI• �C Ar4
"Coning Mslnct Propose Use Lol Area(sy-it) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
to _ 30 2 S
1.6 Water Supply:(M.G.L C.40,§54) 1.7 Flood Zone Information: La Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal 0'un site disposal system ❑
Public Private❑ Check if eslllr�
SECTION2: PROPERTYO;VNERSHIP!`
2.1 OwnerlofRec rd: OAhvt`� A _ 0I1Z3
SKoMl,vs (9evt,(upMt, L
.iT�me(Print) City,State,ZIP
City,State,
No.and Stre��— Telephone Email Address
SEC ION 3: DESCRIPTION OF PROPOSED WORK°(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work: f As O uts
4
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: O
d ft7cial Use Only
Item Luber an Materials -
1. Building .$ I. Building Permit Fee:$ indicate how fee is determined:
❑Standard City/Town Application-Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 2�91her Fees: $
4. �Icchaticnl (HVAC) S List:
5.Mechanical (Fire S Total All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:
6.'rutal Project Cost: s A OF, ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Cunstruction Supervisor License(CSL)
oS"� � �V..{k`` _ License Number 1 Expiration Date
Nano of CSL Fl l7dd�er List CSL Type(see below) v
P.6. V n� zoo -Type. '. . - Description
No. and Street -
/�/,Q,,� U Unrestricted(Buildings u to 35,000 cu. 11.
Ole h� /"r' R Restricted 1&2 Family Dwelling
6ty/ruwn,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
q G SF Solid Fuel Burning Appliances
5-Pk—LGZ_3 (/`P 1 Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Comp:my Name or4IIC Registrant Name
No.and Street - Email address
City/Town, State ZIP Tele hone
SECTION 6:'WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L: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 IsitiancSof the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7u:OWNER AUTHORIZATION TO BE.COMPLETED.WHEN•
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
I,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.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in t ' applic ior trued ac rate to the best of my knowledge and understanding.
U/ rye,
Print Dwner's a orized Agent's Name(Electronic Signature) Dale
NOTES:
I. An O+ r 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(FIIC) Program),will lLyj 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
ion Supervisor License can be found at www.nas,.��ov'J n
w+vw mass eov'oca Information on the Construe p - �
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. R.) "A_.(including garage,finished basementtattics,decks or porch)
Gross living area(sq. ft.) - Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalf/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"'roGd Project Cost"
QTY OF SALEA MASSACHL SETPS
BugD7NG DEPAR7MEw
120 WASLIDJGTCN STREET,3'D FL00R
IkL.(978)745-9595.
K1 FAX(978)740.9946
Ivi6ERI1?YDRISOt�I.L
MAYOR 7)ICMAS STAEM
DjREcroR OP PUBLICPROPERTY/BUILDING amamONER
Construction Debris Disposal Affidavit
(required for all demolition and,renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris, will be transported by: �^
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Si ture of applicant
Z3 � tS
ate