14 PRESTON RD - BUILDING INSPECTION iq I'hc C ununumvcolth uP blussachuscus
Dourd ot'Duilding Regulations and Standards CI"I'N' OF
sl Massachusetts State Building Code, 73D C'hIR SALEXI
Herod Itar 2W
I L .•
Building Permit Application To Construct. Repair, Renovate Or Demolish a
(Arv• or ruvr-Fuarrin Dire liglr
i
1'his Section For Official Use Oi l
Duilding Permit Number: I Date A lied: l
Building 011icial(Print Mom) Signature Die
SECTION I: SITE INFORNIATION
I.I Propert Address: 1,2 Assessurs,$lap S Parcel Number
I.la Is this an acceotcd street? •es no - ,Map Number- Purcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/oning District I'ropnud We Lot Arco IN 11) Frontage(11)
1.5 Building Setbacks(R)
Frunt Yard Side Yunls Rear Yard
Rayuired llrovidcd Required Provided Required Provided
1.6 Woter Supply:(M.G.I.c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Prirulc❑ Zone: _ Outside Flood Zone? Municipal Cl On site disposal s)stem ❑
Check if es❑
SEC TION 2. PROPERTY OWNERSHIP'
2.1 (D'.rw4nie of$'Vev
S
Name(Print) City,Slate.ZIP
%C( 'y"er7JrJ �c� �7�-'ZS; o//
No.and Street telephone Email AJdress
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
I
New Construction ❑ Existing Buildin Owner-Occupied ❑ Repairs(s) O 1 Alteration(s) ❑ 1 Addition ❑
Dentulition ❑ Accessory Bldg.❑ Number of Units_ (her ❑ .Specily:
Brief Description of Proposed Work-: I
Z rASUG/4Q?b
SECTION 4: ESTIMATED CONSTRUCTION COSTS
itcol Estimated Costs: Official Use Only
I l.abur and Materialsi
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
_'. I:'learical
❑ w Standard City,Tun Application Fee
S
❑Total Project Cost t(Item 6)x multiplier -- s _
1 I'lumhi"g S _', Other Fees: S_ z/^/
J, \l"hallical ill\ W) S List:.- -'---
c \1"Itanic.d ifve
�u +rrssion: rota) .\II Fees: S --------
C11"k "la. Chcck AllIkIlllll: C.tih \mmmt:
n )'uml Prnject Cast S 6f 000 _. ._— _. __ . .
(Dr p P.iiJ in Full ❑Outstanding Ilal.unce Duo:
SE('1'It)N S: CONS FRUCTION SERA U FS
5.1 CunstrucIimiSupeni%orI.icenselCSI•) /toTiZ�3 5- 3
�C�+ a �r I letn.re \'uuthur I plraliau l):Ile
\'anw al'l'Sl. l snider
C Ilstl'SL I')pelseeheluwl__,--.__—.._
G )Pu 1)cxripliun
No. .nIJ Sir"t
lnresiricicd l lhlildin`s ti Its 11,UIIU nt It.)
R lJC%oi.lcJ LC2 P.unil Dtt elfin
Cilcil'ow n,Slalc,Lll' \t \Loon
NC R,alin Cos erin
...—. A N'indow.wd SiJin
7ql- U r St. Solid Fuel I)urning \ppliunces
7 Y / I huulutiun
ll•Ic hone 14naii aJJnss U DenxJitiun
5.2 Registered Ilume IImp,�rro%eemenI Can tracfor(II IC)
IjC 4-5& ('J�' � III:Reg6tr tiun Numiwr li pindi m batu
Ili�nnpgtta�l corIII Reg'I woe
No. wsd�lrectim lltt'"'�� Email address
City/Town, State ZIP roc hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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? ........ ❑ No ...........Cl
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
TO
I, as Owner of the subject property, hereby authorize r "u4'VL-"✓I /t e 4A—�
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Umier's Naine(Elcctrunic.Slgnuture) ute
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
cons fined in this applicatiof is true and accurate to the best of my knowledge and understanding.
I'rint Ihwnur's or AwhoriM Agmtt's Nauru Ili lccirooic Sianaulru)
NO'rES:
I. .\n Owner who ubtains a building permit to do his.her own work,or an owner who hires an unregistered ounlractur
i nut registered in the Hume Improvement Contractor(HIC) Program), will no have access to the arbitration
program or guaranty fund under M.G.L. c. 112A. Usher important inlornsalion on the HIC Program can be lound at
\,%"% n`.n, `tA I Information on the Construction Supervisor License can be found at tt,t,t ni.l,+ "-c ,q„
\\'hen substantial wurk is planned,pruside the information below:
Total Ilour area I sti. R.) _ I including garage, tinished basement atics. Jocks or porch)
flobilablerounscuunt .- -. ... . _
Naatberof hcdrooms _ . .
\umhcral'halitromns . . . _ , \amherul'h;dfholhs I
I\pu of 11c.1611g i)dent _ \'anther„1 Jcuko- porches
1)pu.`ICOohlty :)0011 I'ni1,1.eJ Opelf
t "l oral Project Square f onlagc"111m 11c .uhQ11111CJ IUr"1%,i.11 Projc6l Colt- 6Gw