11 THOMAS CIR - BUILDING INSPECTION The Commonwealth of Massachusetts
rrQQ Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7`h edition Wilbraham
^ Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One-or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Number: Date Applied: a
,
�^ Signature: �0. 23• b�j
Building C mtssioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Properly Address: 1.2 Assessors Map& Parcel Numbers
A
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(ft)
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 Ee Private❑ Zone: _ Outside Flood Zone? Municipal WOn site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner]of Record: c t� �A♦
A-Vk ,j /
Name(Pant Address for Service: H
' `� htl - )n-3oua
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction IN Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ - Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Workz:�' ge'T
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑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: $ '7 po o ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CS b100,1 'fLJY f Joto
Aj;�k,,,jA %1 r z License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) do t%
'l Cam,:n..r,.n 1) SJF Iry 9 /fir OiS.s b
Addrt� Type Description. t
�—� U Unrestricted u to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
to(-,) - RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale
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 .......... 19 No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 _ as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by thi:z Euildit:g pearti:application.
Si nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Aget,t hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. AA
AN'
Print Name
Signature of Owner or Authorized Agent Date
Si ned undee'the pains and penalties ofperjury)
NOTES:
I. , n 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 I O.R6 and I I O.RS, 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 halfibaths
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"