19 SABLE RD - BUILDING INSPECTION (2) r �
The Commonwealth of Massachusetts
s i.1 Board of Building Regulations and Standards C1 FY OF
Massachusetts State Building Code, 780 C NIR SALLM
I P� B Wlding Penult Application To Construct, Repair. Renovate Or Demolish a
4 One-or Ttvu-Family Dwellbt.K
This Section For Official Use Onl
Building Permit Number: Date Applied:
1/ Di
fhJdmg Olticial(Print N;une) - Siytatu Date
SECTION I:SITE INFORMATION
1.1 Property Addr s: 1.2 Assessors Map& P cel Numbers
I.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Coning District Proposed Use Lot Area(sq It) Fmluage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Requited Provided Required Provided
1.6 Water Supply:(M.G.L c.JU.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone?
Check if es❑ Municipal ❑ On site disposal system ❑
IJ
Ow rt SECTION2: PROPERTYOWNERSHIPt
rle�oeco m_ N�
IQ(PrVinl) , ' 'li (�Stal0.l.IP
No.and Street Telephone Email Address
SECTION J: 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:
(Labor and Materials) Official Use Only
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
'. Electrical S ❑Standard CityiTosvn Application Fee
❑Total Project Cost'(Item 6)x multiplier _ x _
i. PlumbingS 1, Other Fees: $
4. \Ixh;micl III1':1('1 S List: L
t, \lechanle,J IFirc
5n presslon) S Total :\II Fees: S
Total Project Cost: S $ heck No. ('heck Amount: _ __— lash :\nunurt: .. . -
❑Paid in Full ❑Outstanding B tLuoe Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Sup rvisor License(C'SL)
�^^ A ,n
W N/ � License Number Pcpir;uiou Dale
C List CS[. f)Pe(sec helusel
No, and Slr .._. .—
U 11.)
H Restricted Ii;2 Family Dwellin
C'L0 oml..Slate,LlP V M1I 7la.,onry
RC
W'S N'indu.v and Sidinig
SF Solid Fuel Burning Appliances
I Insulation
'I elc hone 1(nlail address D Demolition
5.2 Registered I1yt`tf�1 Improvement Contractor(HIC)
J V C-A01—"0-/\— IIIC Registration Number Expiration Date
I U ,Coat an) N,Dun,o� Regis\�l�l Nan �
No.and S reel � Email address
City/Town,State,ZIP fele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.it. 152.4 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 Iss ce of the building permit.
Signed Affidavit Attached? Yes ........ No...........❑
SECTION a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
Print Owner's Nume(Electronic Signature) Date
SECTION 7b: OWNEW 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 application is que and accurate to the best of my knowledge and understanding/� /I /
Print owner's or:vulhorircd Agent's Namc(1(Icctronic Sigmnure) 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 Hume Improvement Contractor(HIC) Program),will na have access to the arbitration
program or guaranty fund under I.G.L. c. 1 12A. Other important information on the HIC Program can be found at
ltstlt ow" of ,y.l Information on the Construction Supervisor License can be found at m%> k ma,; gpv dpB
2. When substantial work is planned,provide the information below:
Total floor area lsq. R.) _ (including garage, finished basement'attics,decks or porch)
Gross living area(sq. it.l _ - Habitable room count
Number offireplaces __ Number ofbedroonis
Number of bathromlls Number of half haths
I)pe of healing s)stem _ ._ Numbcr of decks, porches
I\puofeoollllgs1stctn Fllflosed _. _ _ -_ (!!Tell
I
1 "fond Project Square Footage"ma\ he substituted fur"fot;d Project Cost"