9 VISTA AVE - BUILDING INSPECTION (2) Cr"' t
The Commonwealth of Massachusetts �p RE�•EIVE
Board of Building Regulations and StandaraS'SPECTIONAL S S RVI OF
Massachusetts State Building Code, 780 CMR EM
mm���� �p��yy evisedMar2011
Building Permit Application To Construct,Repair, Renovate'6t'D211toM a 3.0
One-or Two-Family Dwelling
This Section For Official Use.Only
Building Permit Number. Date Applied:
Building Official(Print Name) ..Signature Date
'SECTION 1:S1TE INPORA'IATION
1.1 Property Address: VZ° 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street9 yes_ no Map Number Parcel Number
13 Zoning Information: "-- -- - - - --- - - 1.4-Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Budding Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water pply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
u
5 2.1 Owner'of Record:
'gC
Name(Print) City,State,ZIP
No,and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) fiYf Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
B ' f Descri lion of Proposed Workz:
SECTION 4:'ESTIMATED'CONSTRUCTION COSTS
Estimated Costs: Official Use Oni Item Labor and Materials) y
1.Building $ J�Q Building Permit Fee: $ Indicate how fee is determined:"
2. Electrical $ ❑Standard Civrown Application Fee
❑Tota}Project Coat'(item 6);x mu}bpher
3.Plumbing $ 2. Other Fees: $ :.
4.Mechanical (HVAC) $ LisT.+
5.Mechanical (Fire $
Suppression) Total All Fees: $- t
Check No'. Check Amount:' Cash Amount:
6.Total Project Cost: $b�Q ❑Paid in Full ❑Oatstandirtg Balance Due:
'50 Mra, � ro 1� C . 130X S �
O((A cis
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C.S 06 t f&
1 :- yb �v2tu7-P License Number Expiration Date
Name of CSL Ider
}../ S List CSL Type(see below)
No.and Street y,� T , Description
L)q rJ '/ �)90S Unrestricted(Buildings u to 35,000 cu.ft.
Restricted 1&2 Family Dwelling
Ci own,State,ZIP M Masonly
2 L RC Roofingvering
WS Window and Siding
SF I Solid Fuel Bruning Appliances
'j ;l g4419s4 ����Z�Yrts rr�G �� I Insulation
Telephone Email address -CCJ4( D Demolition
5.2 Registered Home Improvement Contractor(HIC)
1 t HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name - -
No.and Street 7 S Email address
Ci /Town,State,ZIP O OTele hone
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
I,as Owner of the subject property,hereby authorize P Y11' t n � i e 6 ➢_P
ii
to act on my behalf, in all matters relative to work authorized by this bSiding permit application.
A (L A QrN2u� n/,t17�n�F
Print Owner's Name(Electronic Signature) - Date
,Q SECTION 7b-OWNEW 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.
6 a
Pcint Owner's or Auth ectmmc Signature) Date
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 MG.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dm
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.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"