6 TAFT RD - BUILDING INSPECTION (4) ck
The Commonwealth of Nfassachusetts
�. Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 C VIR SALEV[
Revised klar 201l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
�? One-or Tivo-Family Dwelling
Chis$dchonForOfficial Usti Only
Building Permit Number: D' Applied.:'
Building off.
(Print Name) Dat
S IT $ NSECTION I: F ATION LI Property Address: 1.2 Assessors Map& Parcel Numbers
T/9GT/�p
I.Ia Is this an accepted street?yes_ nu Map Number Parcel Number
F
Zoning Information: 1.4 Property Dimensions:
ng District Proposed Use Lot Area(sq tt) Frontage(it)
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 yesEl
SECTION1.. PROPERTY'OWNERSHD''
2.1,-Qwger[oPR;; / Sri �t yrr r�GG / S' 70
Name(Print) City,State,ZIP -
/c�/_ T GT 2f, ' Y-7 5// -5raa f
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED.WORK''(check all that apply
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Cl Number of Units_ Other ❑ Specify:
Brie Description of Proposed Work': UJ /2,-/Z
ovi's/c/�s 7b' /wc<t .- zs. rtsS c�.L -,2o c Zyio T
f� lDr/lvt crLr� os.le � s 4
c� �1✓ 1ycl�fi I� G'� i
SECTIONN 4: ESTINIATED CONSTRUCTION COSTS-
Estimated Costs:
Item Offteinl Use Only
Labor and Materials
a , I. Building $ /�/OpU 1..Building Permit Fee.S` Indicate how fee is determined:
l 31 ❑Standard,CityiC6tvn,Application Fe&
3. F.1"[r`.tl $ ❑'Potal,PiojectCase(Iternh) multiplier e
3. Plumbing i 2. Other Fees: S
t List:
{. Mechanical (1IV.\i;) 4
i. %fech:utical (Piro
(a l cQ ,Sn + +ressiun) _ l'utal All Fees: i_
- Cluck No. Cheek Amuunt: Cash :\muunr.
6 I'utal Project t wit S /�/L f ❑ Paid in Fall Cl Outstanding 13;dmtcc Ihte:
r
SECTION 5: CoNS"rRUCI•ION SERVICES
5.1 Cotrstruction Shghervisur License(CSL)
License/Number Gepiration Date
N:une of CSL I Ioldcr �L List CSL Type(see below)
jRC
ypC Description
Nu. and Street
D Unrestricted DuiWin s u to 31d1 cu. tt. '
R 12estrictcd 1.4c2 Famil Dwellin
City/Town,State, Z VI Nlasonr
Root'n Cvrin S Window IN
Sidin
SF Solid Fuel Burning Appliances
I Insulation
Nla hune Email address D Demolition
5.2 Registered Home Improvement Contractor(NIC) - Mgso `�
MC Registration Number Expiration Date
I IIC Company Name or tllC Registrant Name .
-C —�ir'Scb
No.anjSilvet O�9/r IY� G Email address
Ci ITown,Stat . IP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 1 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 A THORIZATION TO DE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ns 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: OWNEW OR AUTHORIZED AGENT DECLARATION
Bye below, I hereby attest under the pains and penalties of perjury that all of the information
lication istrue and accurate to the best of my knowledge and understanding.
7rnurimd::\;ent's Nan (E ectronie signature)
Date
NOTES:
I. 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 n_it have:recess to the arbitration
program or guaranty fund under M.O.L. c. 142A. Other important information on the IIIC Program can be found at
w ww m:u:.euvhrea Information on the Construction Supervisor License can be found at��ww.mas . •u_�-dL
2. When substantial work is planned,provide the information below:
Total floor area(ski. 11.) _(including garage, finished basement/attics,decks or porch)
Gros; living area(iq. ft.) _ Flabitable room count _
Nmmber of flrepl.tce.i,-,__—____ Number of bedrooms
Number ofbathr,,oms Number ofhalbbaths --_-- _.
I'vpeofhealing;yilcnh _ -- . .—_-_ _-- Numberof.Iccks,' porchcs
)peofcaolim� ;yacm f{ncloicd Open
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