31 REAR WASHINGTON SQUARE - BUILDING INSPECTION 7101L' � z �5S01CAR- SsO�{
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts.State Building Code,780 CMR,70'edition OF EM Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a I,2008
.One-or Two-Family Dwelling
"7�It[sigcti'z., Pl'reil£4QIy.
Buiijmg)�etlitit:Number '3 � `` �?e�j�plied
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Signature
,,. 13oi 9C9tnmtss4 nspgctorofBm aJ. ate
1.1 Propei7,Ad1dress: u 1.2 Assessors Map&Parcel Numbers
1.1 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❑ Private❑ - Zone: _ Outside Flood Zone? Municipal Cl On site disposal system ❑
Check if yesO
SECTION 2;RYt(d .. . . b YN,RSHJV
2.1 wner',ofRecJ,{'d: �r� A,
/`tr'-GAt P( C�h� .///s� S7Z 't_ �cS��
Name(Print) - Address for Service: -
-2 y s -si �
Si . , .Telephone'
SECTIUl�t 3 bERIP IOIV tFRf}PCl$EDVORIZ'(check sll that aPPly)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number ofUnits Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4. ESTEIYIATEpCt)iKSTRUGIIOIV,CO§ 8
Item Estimated Costs: T�ffieasl Lase Only
Labor and Materials
1.Building $ 1 Bwl mg Permit 11Fee $ Indicate how fee is determined:
C1$tanda(td Ckt)+fiPowi ApplieatiomFee
2.Electrical $ ZTota1 Efbje$`fit'hem 6 iculti`lier x -
nIF ) . P ,
3.Plumbing $ � pbs r
4.Mechanical (HVAC) $ sJf
5.Mechanical (Fire
Suppression $) TotalA'IIPs
Check No Check -mount: Gash Amount:_
6.Total Project Cost: $ �Cj UQ� ❑pmd In Fall .Cl Outstanding Balance Due:
sECTrt N snlsmxtclfl tss> 1 �5 ,
5.1 Licensed Construction Supervisor(CSL)
ML License Number Expiration Date
Name of CSL-Holder V`- List CSL Type(see below) y
��K N rLc> U`P�S_ _'Uo A Q," L I)LsGd'tiom
Address g /° n U Unrestricted(up to 35,000 Cu.Ft.
A,f�C �/Jtit _ R Restricted 1&2 Family Dwelling
Signature M Maso Onl
T7%__P_ 7 �J�Sj 3 RC - Residential Roofin Covering
Telephone WS. Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation.
D Residential Demolition
5.2 Re 'atinr 1 H to I tprovement Contraq or Q xQ. S
HIC Cot)ipan Name or C Reg t ne LL.. Registration Number /
Addre 7k 761df g3l3 Expiration Date _ �I
Signature Telephone
SECTIONc6, WORKERS'COMPENSATION IN URANCE AFFIDAy'IT(M.G L.t.152.§ 25C(6))
�. _.,.., r .
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 .. ❑
SEC'I�IpN9s:"O�'NERAUTHO A'ClQlsi, 6>IEF� lr1�L I�WIIEN
„pW1�lER'S AQENT OR COITRA'CTOR APl'f5 O$ UJIsIFRMIT -:
cx C J as Owner of the subject property hereby
authorize ` �� � to act on my behalf,in all matters
relative to work authorized by this buildin permit application.
Si ature of Owner Date
r? ' -
,s>crCo _zb olx�- oz >lA1Ii �zoN:,
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
c� l
Print Name
Signature of Owner or Authorized Agent Date
Si red under the urns and enalues of er'u
F(�TRS
I. 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 I10.R6 and 1 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 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"