7 S MASON ST - BUILDING INSPECTION � t
4d-1
The Commonwealth of Massachusetts Town of
Board of Bwlding Regulations and Standards
Massachusetts State Building Code, 780 CMR, T"editionBwWmg Dept
Building Permit Application To Conswct, Repair, Renovate Or Demolish a
One• or Ttco-Funtih Duelling
This Section For Official Use Only
Date Applied:
rmit N ber
Budding CominissiorI Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map d Parcel Numbers
pv 7754 AV, SDaI 57— C9 Parcel Number
1.la Is this an accepted street?yes no Map Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq n) 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.40,154) 1.7 Flood Zone Information, 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
-----------------
2.1 Owner offRRecord-
Name(Print) Address for Service:
Signature Telephone
SECTION 7: DESCRIPTION OF PROPOSED WORK'(check all t apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': /tom O — el= C/
c5'G � f/6w OATS
r�u
11
r1r Cl.-fi�/
felg
SECTION 4: ESTIMA ED CONSTRUCTION COSTS
Estimated Costs: Offlclal Use Only
Item Labor and Materials
1. Building f 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical f ❑Total Project Cost'(Item 6)x multiplier x
} Plumbing f 2. Other Fees: S ( ��
4. .Mechanical (HVAC) S Ltsl.
t .Mechanical (Fire S Total All Fees: f
SU r[$SI00
Check No. _Check Amount: Cash Amount:_
6, Total Project Cost S � 0 Paid in Full 0 Outstanding Balance Due:
i
SECTION S: CONSTRUCTION SERVICES
5.1
/Licensed Construction Supervisor(CSL) C9leyg4 5— // �l2
yscJ7- -?< License Number Ev iratlon Date
N4=of(vf(U. llplder
61 List CSL Type t>cc below)
AJ e Type Description
U I Unrestricted Jup to 33,000 Cu. Fr)
i nature
�^ R Restricted 1&1 FamilyDwellm
; 7,2 7 Zf2 --0/0 N "anon Only
RC Residential Raofin Covenn
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 egistered Honu;Improvement Contractor(HIC)
HI C MY44
e oar H-W citt1hrant Name C� Registration Number
d
� 72 e 97S 7VO a/C// <l z 0i 20/v
— E ration Date
ignarure Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52./ 2SC(6))
Workers Compensation Insurance affidavit must be cogiplcted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan5p,6f the building permit.
Sig nedAffidavit Attached? Yes.......... e No...........0
SECTION 7n: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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I. ^/� „ �0 yG�-�� ,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.
to?cfel�5-
Signature of Owner Authorized Agent Dale
(Signed under the sins and penalties of per u
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 W 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 I0.R6 and 110.115, 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 halfbaths
Type of heating system Number of decks/porches
Typeof cooling system Enclosed Open
3. "Total Project Square Footage"may he.uhsululed for 'Total Project Cost"