9 SABLE RD - BUILDING INSPECTION \ r '
I The Commonwealth of Massachusetts Town of
Q
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR• 7"edition Building Dept
�J Building Permit Application To Construct. Repai • Renovate Or Demolish a
One- or Tit o-Faindv Dis el ing
This a ion For Official se Onl el
Building Permit Number: D to Ap lied: b eZ 6
Signature: (city,
Building Corrimiss, er/Inspector of n Date��
SECTI N 1 E INFORMATION
i.l Pro erty Address• �J 1.2 Assessors Map& Parcel Numbers
Ma Number Parcel Number
I.Is Is this an accepted street'?yes no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Side Yards Rear Yard
Front Yard
Required Provided Required Provided Required I Provided
1.6 Water Supply:(M.G.I.c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private O Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 caner'of Recot n A h
�t) LLt cJc- S —1 �---
Name(Print) Address for Service: ,
Signature Telephone
SECTION): DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building wner-Occupied Repairs(sjL" Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg. O Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': 14'•1 o I —
J
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building Permit Fee: f Indicate how fee is determined:
I. Building S
❑Standard Ciry/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
J Plumbing S 2. Other Fees: S
4. .Mechanical (HVAC) S List:
9 .Mechanical (Fire S Total All Fees: S
SuppressionI
pq Check No. _Check Amount Cash Amount:_
6. Total Project Cost. S to 0 O 0 Paid in Full 0 Outstanding Balance Due:
e
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 0 9 y.) L 3 5; ( Y— ( C�
' �C16hl,.a License Number Expiration Dute
N,4me ul'CSL- HplJer
U q List CSL Type(see below)
Address T' Descri non
U Unrestricted u to JS.000 Cu. Ft.)
v R Restricted I&2 Family Dwelling
5i nature M I Masonry Only
S 3 RC Rcs'dennal Roofin Covering
Telephone WS Rcsidertnal Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 R�gIstered Ho a Improvement Contractor(HIC)
L. o , b�ilrc�.r / a D R 1
HIC/oy any Name or HIC Re tstrant Registration Number
Add E,-2
Expiration Date
Signatue Telep one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... O No........... O
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, Le .q G;i b--e L.V C as Owner o 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. _r,
Print Name
Signature of Owner a tit or z gm Date
Si ned under the sins and na ties o ru
NOTES:
I. 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 W 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 I IO.R6 and 1 IO.RS,respectively.
2. When substantial work is planned, provide the information below:
Total noon 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 coaling system Enclosed Open
t. "Total Project Square Footage"may he substituted for"Total Project Cost"