2 SAVONA ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SA EM
I , Nfassachusetts State Building Code, 730 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tsvv-Family Dsvelling
This Section' ial,940111y.
Onl
Building Permit Number:,'.- Date Applied:,
Building Official(Print Name) �Signattud.'.r Date
oV6IV . S T . SECTION L SITE7NFORINIATION'
1.1 P mperty jiddress: 1.2 Assessors blap& Parcel Numbers
1.1 a Is this an/accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required - Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?Public❑ Private❑' — Check if es❑ Municipal❑ On site disposal system ❑
" SECTION Zc; PROPERT1f'OWNERSHIPL'''
2.1 Owne io Record//-�
Name(Print) City,State,ZIP
2 5dr/ Q—J��
Noeet Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED.WORKr(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Atteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specity: .
Brief Description of Proposed Work 3:
C �
SECTION 4: EST RNLATED CONSTRUCTION COSTS',
Item
Estimated Costs:
Official Use Only...
Labor and iVlaterials
1. Building $ I..Building Permit Pee.S' ` ' Cndicatehave fee is determined:
I f��tti�al $ ❑Standard,City!'Cuwn Application Fee.
2. `
❑Total,Project Cost(Item 6)x multiplier x
3. Plumbing S 2 Other Fees: S
1. \lechanical (11V.w)
i. Mcchanicil (Fire $
So , ressiun) _ lbtal:lll Fees: $_
^II Check No. _Check Antuunt: C;uh Aulomu:--
h -1'ntn V
l Project Cost: S ❑ Paid in Full ❑Outslandim,� II:I I;tIlCe )1 W:
Y A a w
h
SEC'CION 5: caNs'l-RUCTION SERVICES
5.1 Construction Superviiiorr License(CSL) /d h / _ tl 3
�� License Number 'Expiration Date
N;une ofCSL I lolder
ZJ j��11 // List CSL Type(sac below)
// }/6 rypeM
Description
Nu.anJ Street T U ted Buitdin s u m JiA00
f191// t//of tV I II V LU �V R d 1&?Famil DwtllCity/Town,State, ZIP kI�R£i Coverin and SidinSF el Burning Appliances
I nTele hunt Email nJJress U on
5.2 Registered Home Improvement Contractor(HIC) f (/ 9 6 / t' 7 � l3
R7✓C tr�s HIC Registration Number Expiration Date
fIIC /11, N nfyrlll stfnntNuna � // /
No.and Stree ✓ �r lt`/� X Q 7�/Z /1r�9/�z Email address
Ci / own,State, 'ZIP / Tele hone S
SECTION 6: WORKERS' COMPENSATION INSUIL\PICE AFFIDAVIT(M.G.L. c. MI. § 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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a: 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 Name(Electronic Signature) Date
SECTION 7b: OWNER' 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(ap I• anon is true and accurate to the best of my knowledge and understanding.
_ 1►y � �--� � 3l T 3
Print Dwnar's or uth Agent's N,une(Electronic Signature) D,ut
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
progr in or guaranty find under M.U.L. c. 142A. Other important information on the HIC Program can be found at
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Inform P Information on the Construction Supervisor License can be found at www _.mas .!.odL
tv w w.m:u.._ov:'ocu
2. When substantial work is planned,provide the information below:
road floor area(ml. It.) —(including garage, finished basement/attics,decks or porch)
tiros; il .livin arca( R.) Ifabithble room count _
s I
III Number nftinplaccs
Number of bedrooms
Numberotbadir,,omi NumberofhalEbadis —
fcpe of heating.iyitenl _---
I)peofe,Ining ;Yife°h -- - - - -- - F.uclosal.
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