28-30 PUTNAM ST - BUILDING INSPECTION ) CAM . cjt:� SC) Ste -
The Commonwealth of Massachusetts RECEI VE
° Board of Building Regulations and StandardANSPECTIONAL S 4Vf
Massachusetts State Building Code, 780 CMR
ig
Building Permit Application To Construct,Repair, Renovate 7J1S)A IJs3 a A & revised
One-or Two-Family Dwelling August 15, 2013
NThis Section For Official Use Only
Building Permit Number: Date Applied:
1 Signature:
Building Commissioner/Inspector of Buildings Date
SECTION_ 1: SITE INFORMATION
l 1.1 Property Is /Address:oyf� �m 1.2 Assessors Map &Parcel Numbers
s
L l a 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:
Zone: _ Outside Flood Zone?
Public❑ Private ❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
1 Owner of Record:
Ti+.�J� Ile_ d/LNG 'r,m
Name Pont) Address forService:
(9-2
gnature Telephone
_.--- .._...._.- ._._... _.. .__._ _. ... ...______.°._—
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials I
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/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: Cash Amount:
6. Total Project Cost: $ V' ❑Paid in Full ❑ Outstanding Balance Due:
- - I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
e,/ S ��` License Num er Ex irahon Date
Name of CSL-Holder � (J
,� ? .,��J A ,r }, ��JU /�_ S/' e/yl List CSL Type(see below)
Address J/�j �/`E ✓,� �� // T e _ 5,DescriptionuFt
Unrestricted(u to 35,000 Cu.Ft.
R Restricted t&2 Family Dwelling
Signature c-�
.S ,�_3, �__ M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Imp ovement Contra t r(HIC)
HIC Compan Name or HIC Registrant NJ me // Registration Number
o� u. it -h tY sf/U f/3/�m � d
Address �
���� , Expiration ate
Signature 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 FOR BUILDING PERMIT
I, _..//;/VC-S L�ZgArn C- , as Owner of the subject property hereby
authorize Z41 r'e- 4 S' e L--- to act on my behalf,in all matters
relative to work authorized by this building permit application.
ature of Owner Date
AS/ECTIO/N 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, / z2C/ ? CZ-t -.- ,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. [ 1
/l !o /l
Print Nam . /�/ C �
Signature of Owner of Authorize gent Date
(Signed under the pains and penalties of perjury)
_ 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 110.R6 and 1 1 O.RS,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"