95 PROCTOR ST - BUILDING INSPECTION The Commonwealth of Massachusetts
�y�y Board of Building Regulations and Standards Town of
y Massachusetts State Building Code, 780 CMR, 7ib edition Building pep'
DBuilding Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two-Family Divelling
� A Ihis Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building C mmi inner/1 ctor of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pro rty ddress•. 1_ 1.2 Assessors Map& Parcel Numbers
rc�C fo fe t
1.1a 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(ft)
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❑
SECTION 2: PROPERTY OWNERSHIP'
2."wne/r'of Record: �S_Fr0(TO` Y_ 9� S.41�l
Name(Print) Address for Service:
9 7k-- 7 73
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building af Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': .--
—V /
�FJCT[Ok4j ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ / ❑Standard Oty/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ -
Suppression) Total All Fees: $
Check No. �Check Amount: LCash Amount:
6. Total Project Cost: $ /�� aid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) � =,�J --{ rF ir
�JNV "e
L�nse Number Expauo Date
Name of CSS,L H Ider ^ / St List CSL Type(see below) UkI /1 _
Type Description
Address / U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Jt nature M Mason Only
RC Residential Rooting Covering
elephon r/ WS Residential Window and Siding
w,P7 SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2-Registe Ho a Im ovement Co tractor(HIC)
w f /Zell"
HIC Co an Nam IC gist Registration Number
GGp t t Name �
ess
/Expikairion Date
nature Telephone
SECTION 6:WORKER&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
1, 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.
Signature of Owner - Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Pr' t e
Si u e of O er or Au rzed Age Date
ned under a pains and penaltieVof eju
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. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total Floors 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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALL:M
PUBLIC. PROPRERTY
`= DEPARTMENT
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„I. i.• L, \\ \,ip\I. ".l:Fllr � \\II \I, \1\„V •. I • .I'I _
III 'I'&Vie l' I. • 1 \\ .I V_ 'ri L•
construction Debris Disposal Affidavit
(rceluired l'or all demolition and renocatiun \cork)
In accordance \% ill, the sixth edition of the State Building Code, 750 CR]R section I 11 5
Debris, and the provisions of.)OGL c 40, S 54:
Building Permit hi is issued with the condition that the debris resulting front
uperly licensed waste disposal facility as defined by vIGL c
This work shall he disposed of i.n a pr
I 11. S 1 50A.
The debris Will be lr:msportcd by:
(nanlc of aular)
I he debris will be disposed of in
l name ullaalny) -
taJdre,\ of Idc 1111V1
�IL'lldl Ul l• Ut petnut .11\IIIKaIlt
,late