7 S MASON ST - BUILDING INSPECTION (2) 0' 10
The Commonwealth of Massachusetts
T ' Board of Building Regulations and Standards CITY
I
Massachusetts State Building Code,780 CMR, 7a'edition Revised January
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008 _
One- or Two-Family Dwelling
's Section tFor Official Use Only
Building Permit Number: Date Applied: " "'...
Signature: UC'1A
h
Building Commissioner/lnspectofflfildings Date ,
S TION 1: SITE INFORMATION
••' 1.1 ryperty Address: 1.2 Assessors Map&Parcel Numbers
L l 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 ft) Frontage In)
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:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 w er'of Record:
( /'2Q/'QC//.S SDu- l `J�/CeS�r) J7�L2�d'
Nme(Print) Address for Service:
Y.
Signature Telephone
I " SECTION 3:DESCRIPTION OF.PROPOSED WORW(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. El Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': Q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee " • '
❑Total Project.Cost'(Item 6)x multiplier ' x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: �Cash Ameunt.
6.Total Project Cost: $ �"'1500-oo 0 Paid in Full ❑ Outstanding Balance Duei '
SECTION 5: CONSTRUCTION SERVICES I:
5j1 Licensed C�opstyruyctiog5up% ilco • CS )f ---
License Number Expiration Date
Name of CSL-Holder �4(see
List SL Type(see below) z�po
A resS' Type
Description
��A U Unrestricted u to 35,000 Cu.Ft.)
d l&2 F
t i` �rtt—v� LJOY\ Il- Restricted Dwelling
Si n lure M MasonryOnly
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
OI''1 09 ?�(p� — q C'6/ SF Residential Solid Fuel Burning Appliance Installation
l l t� J D Residential Demolition
5.2 Registered Home Im roveme�nt'C/ocnti�c—t,o�rA(HIC)
�stfJ1r. r O 7, ` V— If:�R(n251
IC Company Name or HIC egistra t Name Registration Number
R
Address
xpiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c 152.§ 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 .......... 13'� No........... ❑
SECTION 7a: OWNER AUTHORIZATION:TO BECOMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, t b )r-, A 1!� ^
N�1yya 1 S as Owner of the subject property hereby
authorize Yn 1��.Q /�CC3�u to act on my behalf, in all matters
relative to work authorized by this building permit application.
i ature of Owner Date
SECTION 7bi OWNER' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"