72 SURREY RD - BUILDING INSPECTION 1
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR, 7`t'edition OALEM
ReF S anuary
la Building Permit Application To Construct, Repair,Renovate Or Demolish a I,2008
One-or Two-Family Dwelling
This Section For Official Use Only
t Building Permit Nu r. Date Applied::► Q G
I Signature: 1MV
Building Commission I or of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
L la Is this an accel4ed street?yes �no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Si.,f-4 �»ir�-5 ems__• '�- t�s
Zoning District Proposed Use T Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yazd 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 n site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record:
am (Print) - Address for Service:
J
f1 aL- Y%,v -
Si&atdre Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s),Pq Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':/��,-.o�-c
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ S c+a ,� 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ El 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 $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $��s-� Ch a - ❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
S�3S'3c� ia
Z)�,, /1 r� ��5 License Number Expiration Date
Naameof S4L�-Holder List CSL Type(see below)
V-' ��� r2 ��'�`'�' Description
Address
Unrestricted(up toCu.
R Restricted 1&2 Family
Dwelling
Signature M Masomy Only
,);1' -oz?r -f Ba�.� RC Residential Roofing Covering
Telephone WS Residential Window and Siding
HD SF Residential Solid Fuel Burning Appliance Installation
Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
_)o� Gnrs /
HIC Company Name or HIC Registrant Name Registration Number
4d4ss
\ ( �» _ any- -r Expiration 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 .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
ter»4-1-z�le as Owner of the subject property hereby
authorize / „ .._—ee"' -.SGa- to act on my behalf, in all matters
relative to work an on d by this building permit application.
9 -�
Si nature ner Date
SECTIO :OWNEW OR AUTHORIZED AGENT DECLARATION
I, Z",�b, zd ,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.
Signature of O er or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 HI.R6 and 110.115,respectively.
77 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"maybe substituted for"Total Project Cost"
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08/21/2009 12:03 9787457012 ANTHONY P CARNEVALE PAGE 01
MORTGAGE INSPECTION
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