10 WHITE ST - BUILDING INSPECTION (4) -- — Fhe ('lrinrth a nsea l(h oI pl us,uc hot set is
O t` Board of Building Regulations and Standards
\IINII II' \I II1
` ! l %f,SSj IIuseJJS Sla(C 13u11 ('ode. 7S0 CMR. 7"' edition sl
r r
Building 1'Cnnil :\pPlieauon o('uusu tic t. Repairr. Renm.ate Ur I)e nuJi,h n K1li's
_11us'
\ (b) or Tlrlr l luru a' /h1 rllinp `-- -_--- -
Thu Ste in For It lal ('se ()nlv
BlllldoIL! PC[' n umher -_- a Apphrd'. .---_-"_ -_- -. -_—_
It a IIJIUF l knnl 1„11111e1r -
�— SECT IN : SITE INFtMMA FION
i1.1 Property A.ddrvss: 1.2 \sses=ors Map & Parcel Numbers --` -_
Mal,tiunlhef I'.u.rl Nulnhcl j
I I.I h this .III dei epltd ,IrCt:� 105 __ IA1__ 1
1.3 Zoning Information: 1.4 Properly Dimensions:
Lot Area is oil Fflnll at!l• It Zoning DI+1nCl Pn,po,cd L'st 4 -_-
1.5 Building Setbacks (ft)
j Front Yard Side Yards Rear lard
ReyuoeJ Pn>v1Jtd RcyuueJ PnnlJedFSewage
rd Put,iJrJ � -
�—
I
1.6 Water Supply: (.%A G.L c. 40. §54) 1.7 Flood Zone Information: Disposal System:
Zone OutslJe Fl1,toJ Zone' On ,Itc Jutw,al +� dem ❑
Public ❑ Pn+we❑ Check 1t yes❑
SECTION 2: PROPERTY OWNERSHIP'
1 Owner e 2 Record: 16,
—�. Qv
%
Name 1 Ifrint) Address for Service
��
r
atty� Telephone
� SECTION 3: DESC'RIPTION OF PROPOSED WORK=(cheek all that apply) __j
Constrw:!ion ❑ Existing Building ❑ Owner-Occupied ❑ Repairs s) ❑ \Iteratnml,) ❑ :\Jchul�n ❑J
Denn hriun Cl Accessory BIJ�•. ❑ Number of Units_ Other Sptu fy
I
Bnet Description of Floi�i tdd %Voh::_ ._.! .� —_ .��-rn,.1�_S af-•__
SECTION J: EST VNIATED CONSTRUCTION COSTS
Estimated Costs: OMc•ial Use Only I
Item _
I !I.ahor;mJ \t:utnals) _._
I Iiu Idme 5 I. Building Permit Fee: 5_ Indicate hit++ tee is dewi nnned:
❑ Sumdard Ci(y[Town Application Fee
I. Flee meal 5 ❑"rutal Project Cost (Item 6) x multiplier x
t. Plumbing 5 '. O(her Fees: S
1. Mechanical (FIVACI $ I List: _ - ---
5. �ltc humcaI if"C 5 — ---
r,aal :\II Fee,: 5 _
>u ,+rr++uml
heck No _ Check Ain,wnc
f, Fatal Project Cost ) 57 0 Paid In Full -- 0 oulslandmi B,1lanir Dut- --
SECTION5: CONS TRLCHONSER1, ICES
r I CS
';.I
fT,c s,I I I I I TV r I
\jm, IT l sl. Iloldcl I t,t ( SI. I%TV ,cc Klo,I
1 111, 111, cd , 111",
I K Rc,11 1,!Cj N-' I I I),,, hi I
-�i- —
I 111 111 r )T I I I
Rt, I? J,
I c1cpholy,
S,dij 1 ail
.2 Registered Ilome linipti-co,ement Contractor (111C)
HIC CEIIIIII.,Ils N.,111C or 111C It"t,al�l I-I—�\ e
lisp
sIgla!ule telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDA VIT 0I.G.L. c. 152. § 25C16))
lli,'orkers Compensation Insurance affidavit must 'I
_be-IL-1 MplelCLIalld sLlhrlllftCd with this 17.idaie I, p,... dc
lhtsatfida>it will result in the denial oJ>e-,-s1uj nee III the building perinit.
Signed Affidavit Attached? es .......... 0 NO 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNEWSAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of th� I property hereby
X0, ambi"'le to act ,Ill Ill., by bait. it all Illattels
;c!::wc to %%ork authoriLed by ihi!t building permit application.
S1411jiure of 0�91�111 . Date
SECTION 7h: OWNEWOR AUTHORIZED AGENT DECLARATION
-- as Owner OrAuthowed \,en( hetchydeklaIC
that the statements and informalionon the toregoine application aii: (rue and acLuiale, to the best or rTY krim%!cdee ind
behalf.
Print Naine
Signature of Owner or Atithoo/ed agent Date
!Signed under The pains and penalties tit perjury) NoTFs:
I. An Owner 1%ho obtains a building permit to do his/her own Durk. ur an owner who hires an Uilleg111CICd II-IIIIALI'l
friot registered in the Home lrnproserrwn( Contractor (111C) Program). will iml hale access to the ,uhill,rion
program or guaranty
v Lund under M.G.L. c. 142A. Other Important Intormationon the HIC Proiziarn LrId
(-,Instruction Supervisor I.censing WSI-)can be found in 7SO CNIR Regulalions I I0.R0 and 1 10 RS ie,pe,lisek
When suh,aannal s%ork is planned, pio\ide the Information helow
Focal floors area .Sq. H.i iinL I udi rig garage. finished hj.SCITICIWAII�S. LJCrKN ilf I't'I,ho
Gw, area fsq, Fr Hahitable noon count
Nurriberct Number A bcdro,m,
Nwiihci ur hathw,rns Numherot Iml: hoh,
he,inne %,Ecm Numhei -t lc,k,, p,i,hc,
),(CfnI mk, d
Votal Pr,,JCLt s;,ILJ.re man he ulbstituied I(r F-r,d Pr„lest t (""11