25 SABLE RD - BPA V I�
a ' --- I'he C•umnwnwe:dth of blassarhu.cus
Board of Building Regulations and Standardstee, CFI'Y OF
tr blassachusclts State Building Code, 780(AIR -\Lli\I
11,10
Building Permit Application To Construct. Repair. Renovate Or Demolish a
(ore-or Tevo-Piunilr D%vv11 .V
This Section For 011icial Use nl
Building Permit Number: _— Date App /. _
7 3o/
IIuilJing Obelus(Prins N une) Signature Dole 's
SECTION I: SITE INFORINaTION
L I Pro erty 1JJras: 1.2 Assessors blap S parcel Numbers
I.la Is this an accepted street? es no Map Number I'urcel Number
1•3 Zonlns Information: 1.4 Property Dimenslons:
Luting District I'ropow Ullae Lot Area(sq 11) Frontage(Iq
1.5 Bullding Setbacks(R)
Fnntt Yard Side'Yurds Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§Sq) 1.7 Flood lone Infarmallons La Sewage Disposal System:
Public❑ Pri%we❑ Zone: _ Outside Flood Zone? Munici ai❑ On site disposal s stem ❑Check if cs❑ P W )
SECTION2. PROPERTY OWNERSHIP'
2.1 O nerl of dt
;unu 1 Print) City.State,LIP
No.and Street rcicphune F.muil Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ I Owner-Occupied ❑ vRepairs(s) ❑ Allerationls) ❑ Addition ❑
m Deolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Spcvity:
Brief Description of Proposed Works: \ 0 P
.� `. n '
SECTION J: ESTI,MATED CO`7STRUCTION COSTS
Ileitt Estimaled Costs:
I Labor;nd.\Luerials) Omclal Use Only
I. Building S CIO7 — I. Building Permit Fee: S Indicate how lice is determined:
2. Flecirical S ❑Standard CityTuwn Application Fee
❑Tulnl Pru at C'-Al Went 6)x multiplier x 1. I'lumhing S v )
_. Other Fees: S-
J. \Iech.olical ill\ \1'I S Lisl:
9 \Irch.mic.tl IFirc — -- —
Su +nessmnl S ratal .\II Fees: S_ — —
r Chcck Vo. Check :\nttnnn: l',ah \u nnum:
n I'mal Project Covt: S 000 — . _._._..
❑Paid in Full ❑(hrisCmding 11.11 mcc Duo:
54s rmuor-rio,*4 SERN,I( Fs
(onstructiol Super isor Liccust I( SO
LA 11,111 Date
iccn.,c NUillhcr
Adas_-
N.mic Wcsl, I Foldvr I M 01. 1,.%N I'"
Description
No mid Slrvct famstrictcd 011111dill"s kiii it)
Cyy,,r�,\q1CC-7 MIM) I..........
KC K4%ilill Cut Grin
WS Window.eIj Sidin
SF 401ij Fuel Iltimills'lippliallces
I tribulation
D 11011011111111
Finjil address
11 Cuillroclor ItIlL)
tole bona
_2 Registered ljorne improl, It I I A ManNor F%pirittiol Date
TO A) Ca
tinipan) Name Or I M Iscitistrant 1�"la
tail address
Nu id Su ;A C303�t
Slate ZIP.......
SECTION 6:WORKERS'COMPENSATION AFFIDAVIT e-
52 25C(6))
Workers compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this odyidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached? Yes ..........C3 No......... C3 OMPLETED WHEN
SECTION MEN in; OWNER AUTHORIZATION TO BE
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
51. 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.
Data
Print
ENT DEC
SECTION7 OWNERWOR AUTHORIZED AG(GE=NTDECLA RATION
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 true.and accurate to the best a(my nowl dile and understanding.
Data
NOTFS-
I. .\n Owner who obtains a building permit to do his her own work.or an owner who hires an unregistered contractor
,lot registered in the Hume Improvollenl Contractor tHIC) Progranil.will nu have access to the arbitration
A, Other important inrarmation on the HIC Prograll,can be found at
protir- can be round at
all,or guanuil) 11und under.M.G.L. c. 142
I illrorinaticin an the construction Supervisor License
2. hen substantial%%ork is pKIII-1— F--- a the info rinatiun bclo%v:
1 including g;lrrge. finished basement atics,decks or porch)
row titioraren(4 11abit.ible room count
(iruislitingarealsy. IT.I .._._.. Njullher tif hedrotims
\tjmbvroI'Iir%:jlInccs \twitivir ul'hull baths
Nuillber it hathroullis \11111hcr o(d"ki, pord'"
I Ile of liv.11ing s)sicill ..Open
ht 1":01,010111Iq \0011
"t.11 Proic6l Square Fool.y!.. 111l1\ he suhdiuneJ tier l'ol-11 Iroject