17 SABLE RD - BUILDING INSPECTION - ---- I'Itr l',mtm„n"ralth ul :�lus,.trhusrtu I I t Ili
t Board ,d Budding Rrgul:wons and S(andalds \II SIl II' \III Y
\ ; %LlssdchusrttS State Building Code. 751E I. MR. 7"' rdilion sl
Building Permit :\pplicationt To ConsuuCl. RePatr. Rcnmaic OF Dclilk,llsh :I
u,v
\ i Iblr- ou /u„-{,u,til,' {hrllrne _ —___ -- •
I his '-cuoi :or Otticial l'.e OnIY
Edurt Pe
nou uN other Daie AppheJ.
- --
--
li_nFlute
Builduif ('ununi„iooci, ln,jvoo Ilu gs Dai`
SEC'"IION I: SITE 1\Ff)R%l I ION -- --
1.1 Property Yddr•'s: 1.2 .\esessors flap & Parcel Nuurbcrs
\L�n\unihrr
I I e L, thisan accep(ed street:' se,_ -�_ n"____
13 'Zoning Information: 1.4 Frepetly Dinarnsi ,ns: j
Zoning D"I"Ll Proposed Use FIT( A. isy 111 —..— F7ooi.,ge ilia
i
1.5 Building Setbacks (R)
Front Yard time Yards Rear Yard
ReyurteJ Provided Reyuued Pnnided Reyun s•d Pw,iJcd
1.6 Water Supply: 0A G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone ._ Outside Fl,wd Zoncl Municipal ❑ On ,ua dulr„ul ,y,Iam ❑
Public ❑ Pncate Cl Check if ves❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
Name i Pi inn Address For Service: -- -------
I Signature
Telephune
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply) _
F�7-,, tr�ction ❑ FAct
sting Bulding � Owner Occupied ❑ Repain(s) ❑ : lteranon(,) ❑ :Wdi;iun ❑
li Dernuluiun ❑ essory Bldg. ❑ Number uY lJnits_ Other ❑ Spcci Fy
ffi,et D—t-1Vion of Proposed Work':
l SECTION a: ESTIMATED CONSTRUCTION COSTS
-.—..--- Esumated Cos:S: i .
Item Official Use Only
it-ahor and Materials)
I Bulldmg �y r I. Budding Permit Fee: 3_ Indicate hook tec a Jcici nuncJ
5ob .❑ Standard Citylfotkn Application Fee
- '. Ei fec(ncal ---�$ __ ❑ ro(nl Project Oust' (Item 6) x multiplier
t.. Plumhing '� 2. Other Fees: 'S
1. :Mechanical lH\'ACI 'S ---- List ------ - --- .
SS Mechanical IFuc Gall :YII Frey: t7
�utore", r)
ot7 Check No Check \m,unt ('.i,h \m,nun _
0 Folal Project Cost I ) 5-C)(::, 0 P.uJ In Full 0 Outsi.u,Ju " B.iLuac Ihlr
SL(.FION5: ('ONS'I'R(,(' ['IONSf-R%*I('I--S
L"C11'e Nmmhir I yll '1 2
\.tillcoli, SI, 11,fljcl L 11 \I C sit I
R( f?r,,JC11l1jI R""I...c
H,"domt.tj S'd ': I u,I li,:l
5.2 Registered Iforne Improvement Coinfractor I IIIC)
tmili,mo \,ini:or HIC Rcuisti-int Name \mmh:g
F
SECTION 6: WORKERS* COMPENSATION INSURANCE AFFIDAVIT 1M.G.L. c. 152. § 2506))
LOWNEWorkers
WorkersCompensation Insurance affidavit must bec,,mpleted and uhnimed with this ippli,ao.m. F.ill ure [,t pt,) jdc
"' 'e ( w
this affidavit will result in the denial tit the Issuance of the building perinit.
Affidavit
Signed Affidavit Attached'? Yes ... .. No .
SECTION
CTI
ECTION 7Ea: OWNER AUTHORIZATION TO BE COMPLETED WHEN
0 OWNER
OWNER'S
W�NE 'S AGENT
R S tG E'NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner ot tht property hereby
i alithill.ze to Uct cw In-, in all matters
;e!::n%c to %ko,Kauthorized be Ihms building permit application.
.Siulatureuf 0,,n,, Date
SECTION 7b: 0"'NER' OR AUTIIORIZEDAG ENT DECLARATION
as Owner or Audioti/ed \gerrheichydeclare
that the staiennentsand informmionon the foregoing application are true and accurate, to the best of my knok%!cJee ,jnd
behalf.
Print Name
SiLm.aureot Owner or Au ligent Date
.S'! i.tried under the pains and penalties ol*perjury)
NOTES:
FI-n Owner who ohlan, la d I nLperm,, to Ju his/her own %% I k. r ;tit o k%ne r whit hires 1 tin re L I,I e I ed iac I ,I
tnor registered mthe Home 1'Pro,emen, Contractor
(MC) Program). ihe .uhmanmi
P program or guaranty tund under .M.G.I. c. 1.42A Usher Important information tin the HIC Prilgrammid
C,'nsilLiclion Supervisor Licensing (('Sl,) can he found in ',SO CMR Regulaiion< 1 11) RO And 111) 145, IC1IICLH1Clk
When uhmannal work IN planned, pio%ide the intoinnation helow
Tonal t1o,irs area iSq. Ft.I lin,luding garage. fim,hed decks �,r
(;Io" hvmg area 'Sy. Fes Hahnable room count
Number ct fireplaces Number ,4 hedro,-,n,
Nmuthei nl h,ohot,mvs NjmhQr,lI h.il: Ijnh,
I she lr hearing .%,tem Ntimbei ,t Jc,k' pi.f_hc,
Ile .I ...�.lmg s,icrn
'r-11A PI''tell ('�"I
Protect SquarePi•otage" Pla% Ile 'UhstItUted I'll