18 SABLE RD - BUILDING INSPECTION (2) GK
T13 - 114 - l(oz R
The Commonwealth ofbiassachusetts ONAL SFRVI I S
Board of Building Regulations and Standards CITY 0
I � AI
Massachusetts State Building Code, 780 CMR IOIb �� eJ iE6r�zrl�
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A' 'ed:
>0
Building View](Print Name). Signature Date
SECTION 1:SITE INFORMATION`
I.I Proper' Address: n 1.2 Assessors Map&Parcel Numbers
I SS P% L
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Properly Dimensions.
LoningDistrict Proposed Use Lot Area(sgll) Frontage(11)
L5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(hf.-.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ Pe
SECTION2: PROPERTY OWNERSHIP,
2.1 Owner'of Record:
iTirne(Print) City,State,ZIP
No.and Street Telephone ' C•mail Addn:ss
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) 13 Altemtion(s) ❑ I Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units—L— I Other ❑ Specify:
Brief Description of Proposed Work': !/ HA40
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cose(Item 6)x multiplier x
3. Plumbing S '?,9therFees: S
d.Mechanical (HVAC) S List
5.Mechanical (Fire Total All Fees:S
Suppression)
o� Check No._Check Amount: Cash Amount:_
6. Totai Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
Ova
SST to ( t5
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1 t t` t�0s5 1 Mq �6G p License Number Expiration Date
Nmne of CSL[folder List CSL'rype(see below) _
-3 Ll Lf A)i N 6-5 G.`1Z �Type - I " . Description
Nanmd Street
rFl9gDoZ Aw y01" e U Unrestricted(2Euni su -l0ing cu. It.)
R Restricted I&2 F;unil Dwellin
Cttyrfown,State,,'ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /Q& 9 S 3 ,�
�lJ5L6 S Cp�✓STi2�Cr `aN HIC Registration Number Expiration Date
H Cu np;my Name of HIC Registrant Nmne
��i Nrrt�E� Cil2 TAtlSTi`iVOMi=Lo ,GO
N vtd eet Email address
Ci /Town,St to ZIP Telephone
SECTION 6e WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.§ 2$C(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:TOBECO@IPLETEDWHEN "
OWNER'S AGENT OR CONTRACTOR ►PPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contains this application is accurate to the best of my knowledge and understanding.
Prin Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under NI.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
www.mm, �oL i;! Information on the Construction Supervisor License can be found at www.mas. ovadus
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) ,(including garage, finished basementlattics,decks or porch)
Gross living area(sq. it.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type oFheating system Number of decks/porches
'rypeofcoolingsystem Enclosed Open_
1. "total Project Square Footage'may be substituted for"rand Project Cost"