14 PLANTERS ST - BUILDING INSPECTION • The Commonwealth of /
Massachusetts a
City of /4� _L
U State Board of Building Office of the Inspector of Buildings
IVl7p Regulations and StandardsMassachusetts State BuildingCode
780 CMR
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
• This Section.For Official Use Only '
Building Permit Number: ate Issued: -
0 Cj Signature:
.Building CoM i sioner5rispec uil i gs :Date
SEt,TION 1 SITE INFORMATION
1.1 Property Ad,dpre3� 1.2 Assessors Map&Parcel Number
e �L/ / / 4sZ Y/t C S
✓ /� i / " r ev Map Number Pare!Number
1.3 Zoning Information: 1.4 Property Dimensions: i
Zoning District property Use Lot Areas Frortto ctft
Building Setbacks ft 1 1 i i 1 1
Front Yard Side Yards Re rlYbrd 1 1
Required I Provided Required %`Provided / Re ufred t ( IllI Pr ovided
1.6 Water Supply(M.G.L.c.40.§54) 1.7 Flood Zone nfgrrmdion: - GS Se 6g6Dispe oit Syst`rrS:j�
Public ❑ Private❑ Zone;1 utside Floo�Zon$ MugrQipal 0 Qn site disposal tsystem ❑
'SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT" �{
2.1 Owner of Record:
t /'( i ( !1 4e u� I r�
I
Name(prior) i i i Addr -
tr t
-�
Si nature t I. i 1 / i ( t Tele bone
2.2 Authorized Agi&4 ' C//
Name(print) t t
i Address
I �
Si natu 1 ! � '\,� 1' I Telephone
SECTION 3—'-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ,-
ENCLOSEDSPACE
Licensed Construction Supervisor: / Not Applicable❑
Name(print)
License Num er
Address
Expiration Date
'Signamre
R istered Home m r ent Co�`tor Not Applicable❑
/J/l�r�e ovee / I6GN�n� J�OSL�
Company Name
Y.K License ber
Address 7 �� O
Expira ion Da e
Signature Telephone
SECTION 4-WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M•G.L.c.t52§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 issuance of the building permit.
Signed Affidavit Attached Yes..... No...
SECTION(~DESCRIPTION OF.PROPOSED WORK(check all applicable)
New Construction ❑ Existm Buildin ❑ Repair(s) ❑ Alteration ❑ I Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify:
Proposed Use: Single Family Dwelling C Two-Family Dwelling ❑
.S L
Brief Description of Proposed Work: `` �r b / /
l�
is ; '�/1-� UG r
SECTION 6-ESTIMATED CONSTRUCTION COSTS ` ' All Building,Wiring,Plumbing,Gas,Fire Suppression and Alarm Fees
Item Estimated Cost(Dollars)to be wdl be paid by the general contractor or owner at time of issuance.
completed by permit applicant ":Official Use Only.
1.Building (a)Building Permit Fee Multiplier
2.Electrical (b)Estimated Total Cost of
Construction from
3. Plumbing Building Permit Fee.,
4.Fire Protection (a)x(b)
5.Mechanical Check Number
6.Total= 1+2+3+4+5
SECTIONS10a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CO TRACTOR APPLIES F?R BUILDING PER
as Owner of the subject property hereby
Authorize 'ZI / C Lc �ff to act on my behalf,in all matters relative to
work authorized by lhi wilding petmi pli [ion.
i
Signature of Owner Date
SECTION lOb-OWNER/A THORIZED AGENT.DE LARATION.
I, ;as Owner/Authorized Agent hereby declare that the statements and
information on the foregoing applicati n are truedaccum ,to the best of my knowledge and belief.
Signed un r the pains and petd[ies perjury.
Print Na
6
—Signature of Owner/Agent Date
FEE BREAKDOWN.OFFICIAL USE ONLY Notes:
Estimated Cost
ITEM MULTIPLIER FEE
Building
Electrical
Plumbing
Gas
Total Permit Fee