25 PURITAN RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards 'RECEIVED CITY OF
Massachusetts State Building Code,780 CMRINSPECTIONAL SER $"I
�,... Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Oy�@igQ]jS11, A 4,Li '
One-or Two-Family Dwelling !! YY AAUUbb L1
This Section For Official e Only
Building Permit Number: Date plied:
Building Official(Print Name) - Signature -Date
SECTION 1: SITE INFORMATION
1.1 Property resl 1.2 Assessors Map&Parcel Numbers
r,(1
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`
2.1 Owner r of Record:
y 9i Cam N �l• t -lv PrN�a spa,
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s);Pf Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : ^s `LaC)F
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 96D 00 1 Budding Permit Fee. $ Indicate how fee is detemimed:
❑Standard City/Town Application Fee
2.Electrical $ 3
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (FIVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees.$
q Check No. Check Amount: Cash Amount:"
6.Total Project Cost: $ /� ❑paid in Full ❑Outstanding Balance Due
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License�(CSL) o C7 I�G't _ ? _ L6
ffL P tis f l-ev„/ License Number J Expiration Date
Name of C L Holder
^ /y— G , 6�O `C (?CA List CSL Type(see below)
To.and Street Type Description
0(9,T U Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/To tale,LI � M Masonry
RC Roofing Covering
W S Window and Siding
SF Solid Fuel Burning Appliances
3O6 $coHLevyrretv- 707& I Insulation
Telephone Email address j D I Demolition
5.2 Registered Ho In roven nt Con I•actor(III �/ (/9
_ t HIC Registration Number Expiration Date
HIC C any or HIC Registra ame� /
`1 Al
CUsrt
No .n tree „n��nl Email ad ress
it (}I[73 V
Ci 'own,State,ZIP &IX-2-10-42,07 Telephone
SECTION 6:WORKERS' 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 FORBUILDING PERMIT
1,as Owner of the subject property,hereby authorize t/i 16/C--�- / �( -..
my ehalf,in all matters r lative to work authorized by this building permit appli ation.
Print Owner's Nam (Electronic Signature) VDate
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
contained in this appli lion is and ace ate to the best of my knowledge and understanding.
k , �?f- 2oiy
Print Owner's or Authorized Agent's Name lectron ignature) Date
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(PIIC)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 can be found at
wNvw.mass. o¢ v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor 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 of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"