55 SUMMER ST - BUILDING INSPECTION (4) -- — ---- Ilie Commom%calth of �Iass.rc hluells
!
t Ht arJ t,I liu!IJing KCgul:uunu and St.uIJ.IrJs ( ilk
\ .y ! 71' cdilnm \II Nlt I!' \I II1
\la.,ac unctls tilatC IIuilJin� ('t,Je. till( '\1H. I ! �I
Ruildim_ I'C!'IIIII APPIiCauofI Fo ('VIIsIIIIit. R Ord lr. RCnn•.atC (h I)entt li.h ,!
(hlt-- nr Ttrn-l•,unth l)nrllin(f
I his Secv Ion For OItlClaI t'se CI I
Ii uJJ ute Pernnt N usher _— _ Date :\ppbeJ
SIClt.rlure ---- 1l _ - - - --- ----�--
IiwIJ;nF 0,11,1nl....... i In.pernrt of 11tu IJni o _ —_ Dale
SECTION 1: S '1'F. INFORMA HON
1.1 Pro crh \ddress:n I 1.2 \.sessuri flap & Parcel Numbers
\lo Nu n!her I .u.J Nuluha
I I. I.! Is this .lit ecrCp!eJ slrcn' ses
l.J zoning Informatio 1.4 Property Dimensions: --- ---- -
Zoning Disimi - Prnl>,neJ I sr Lu! \r�:ny !il fiuntaye Ili! !
Frio Yard P r
a JPn udeJ RLy ! !LJSide Yards Prus!Jed I�1i ,J Rea, Y;ld PI�n IJrJ ai
—�
_--
[.0 "Va—'r Supply: y!6 1.t: 40, §, L1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone:'
Puhh- ❑ Pr•%atc ❑ Municipal ❑ On else Jul>txal w,(Cfo ❑
Check it
f-- SECTION 2: PROPERTY OWNERSHIP'
'~ 1 Owncrl of Recor ----- �`
`• '1au -- --
. „ 1'r.nt, :\JJress lox Sersice:
{•gmur._ relephune —�
SECTION t: DESC RIPrfON OF PROPOSED WORK'(cheek all that upplvl
_ � ❑ Ae ling Bwdfn� ❑ oiwner Ocf Units----
Van
_�_Re!L Cher O S t te!;;uunnl ❑ LAJthmn ❑
--� 1 —
t ssory f31Jg ❑ I lumber a _-- --..
I
SECTION a: ESTIMATED CONSTRUCTION COSTS
I 1
j Vern Csurrl Costs. Official Use Only
tl Labor and Materials) I ___—,.__
I Building —�) IUQQ, DC� ; I. Building Permit Pee: 'SInJ!cate ht�t. (ee is Jrle!mmrJ.
❑ Standard City/Toscn Apphcantm Fee
_ ❑ Towl Project Coot them l s multiplier
? Plumhuee 5 ! i. Other Fees S
4 Mechanical 111VAC1 S
Me 1.ha: c.Il Fire f,'t.!I All fees: 5 --- -- - --... - ---
_-''— _ -----
' ('heck N,i _ l heck \mmnutt ( .!.h \ni'mM
o Fotal Project Cost ! ) ❑ F'.uJ In Full --- OutaanJ!n,� lialan.r Uue
-- s o /J
/ o
SECTION 5: CONSTRUC_HON SERVICES ----- --- — — --
5.1 Licensed C'onslructiun Suprr.isor t(-'S1.)
_7.5C ►1 Jos
LI,:Inr ..\uulher __._—._. I ,pll.aunl 17.ne
I
�.I�ne ni ( s I .•I ee U----- -
0_al- x• - o,•,.I I .I I„n =------
J e --- —
1 I i❑CHn,leJ �np to �` INIII I�U I'I --_-__ -_
R Re,u i,lrJ I,:'' F.unlh DoClllne _ _�
Rl'_
r.lrphonr \15 rR..I J,ml,l %\ nJ .0 d
F\F 4 R,"Juul.d ti IIJ 11,l Jim ulu
jD Re"dent ,J D,In Illl„n
5.2 Registered Home Improvement Contractor (HlC) -
IiIC Conq,,ury Nanle or Ill IC ReglNuant Nance Reg UllVln i❑ Nunlhrr
AJdrev, -
Evpuauou Dane
Signutnrc felephune
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be cumple(ed and ,ubmmed with this application. F.ulure (o pen,IJC
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
R CONTRACTOR APPLIES FOR BUILDING PERMIT
1. y\ I" 1(��fvJ� as Owner of the subject property hereby
authorize 2L IIP2-�l to act on my behalf. in all m.aters j
relative to w,nk authoriz by this building permit alpphcation.
i / I
--- ----- - -�/fig -
------------ --
SlenaturcofOwner Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby Jeclaoe
that the statements and information on the foregoing application are true and accurate, u) (he best of my knowledge and
behalf*V —
Print Name
Signature of Owner or Authorized Agent Date
I.Si med under the am,alnJ cnalties of e(u )
NOTES:
1, An Owner who obtams a budding permit to Jo his/her own work,or :m nw tier ,vho hires .u) unragntciCd cor(ra. ilr
(nut registered in (he Home Improvement Contrac(or (MC) Program), will not ha,e acccs, to inC .0 hioati,at j
program or guaranty find under NI.GIL c. 142A. Other Important infiamation on (he fit(' Program .Ind
Construction Supervisor Licen,mg (CSLt can he tound In 780CMR Regulations 110 R6 and 1 It) R5, ic,pec1ivc1%
When ,uhmantial work is planned, provide the information below:
fatal floors area iSq. H,I including garage. finished he,enienU.iitic N. decks or pnr:h,
GroNN Irving area I Sq. Ft.l Habitable room coon( --- —__----
Number od nrcplaees -- Number of hedroom,
`wnbCl ,It hathIMMIN _ _ Siu1T1hC1 It 141it,h.uh. .
Numhcr ,d Je,k,, p,a,hc,
,penl , nlmg ,,,tern__
i3. "hn(al Prlyect Square Footage- may he ,uh,tituied tar rnt,il Pngec(