33 UPHAM ST - BUILDING INSPECTION (2) t6 - I � - IOSS r - 00
a� the Commonwealth of Massachusetts
"h Board of Building Regulations and Standards CTTY OF
,4` Massachusetts State Building Code, 780 CMR SALENI
Revised Mar 2011
Building Permit Application 'fo Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
-this Section For Official Use Only
Building Permit Number: Dat Applied:
Building O❑cial(Print Name) Signature Date
SECTION I:SITE INFORMATION
.1 roperty Address: 1.2 Assessors Map& Parcel Numbers
3� _
1.1 a Is this ar accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
%caning Dis Biel Proposed tJsc L.ot Area(sq It) Frontage(It) r"
1.5 Building Setbacks(ft) —1
3
Front Yard Side Yards Rear Yard _
Raluired Provided Reyuircd Provided Required Prn ' ed r
rn
z
LG Water Snpply:(bLG.L c.4Q§id) 1.7 Flood 'Lone Information: 1.8 Sewage Disposal System.
Public❑ Priva(o❑ Zone: _ Outside Flood Zone'? — C)
Check if yes❑ Municipal ❑ On site disposal.spem R
SECTION2: PROPERTY OWNERSHIP'
2.1 wner'of Record:
---2tnh Wit, sS� NTt} or4Z— —
Nnme Ifrinq City,Slate.%II t
_ 33 _
o. and Siren
N Telephone I::nail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Afteration(s) ❑ Addition ❑
Demolition ❑ J Accessory Bldg. ❑ 1 Number of Units Other ❑ Specii'y:____ _
Brief Description of Proposed Work':_
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials Official Use Only
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard Cityffown Application Fee
❑Total Project Cost'(Item 6)x multiplier _x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (I VAC) .$ List:
5. Mechanical (fire _
Su i)ression) $ Total All Fees:
Q 6. Total Project Cult S
�� Check No. Check Amount: Cash Amount:q �j --- —
orrr ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�I--�,�'`',I. �� License�t umbel Expuano Date
Nume of CSG IJ to r�liol er
,p pp List CSL Type(see below)
Nu.and Street TYPe Description
U Unrestricted(Buildings up to 35,000 cu. It.)
2LRf�(Od`t R Restricted 1&2 Faniily Dwelling
City/town,State,ZIP
M Masonry
RC Roofing Covering
WS Window and Siding
,ye / SF Solid Fuel Burning=Appliw:ces
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
III 'ompany ume orill Registrmrt Name
HIC Registration NuruhLr Expiration Date
N11
i Qis Go r.O tf
No.and Street Email address
aM Z
a Ci[ /TStat,ZIP �� 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........... ❑
a SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PEILMIT
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
_ lolf3/ f
Print Owner's or Authorized Agent's N,, ulectru
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 find under IvI.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) 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. "Ibtal Project Square Footage" may be substituted for"Total Project Cost'
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