65 WILLSON RD - BUILDING INSPECTION P
3' r, The C't nunonwealth of Massachusetts �— It qt —
Board of Budding Regulations and Standards
.� MitssacI,IiseIIsSIto11]iIdiII Code. 7S0 ('91R. 71'edition ]ItNltll' VIll
pt Building Permit Application To Construct. Repair. Reno,ate Or Ihnrolish ❑ R
(het - r,r Tiro-Famili Dw,e ing 1. �'it'•�'
.>p0 1'his Section For Official Use Only -_
13utldingPcrmil Number: Date ,Applied:
S� Stgnalwe: _ ��.�
�J Building('umm1"to d In>xaur d Bwldines Date
L - SECTION 1: SITE INFORD.IA'HON
LIProerty :\ ress: ,/� 1.? :\ssessurs Map III Parcel Numbers
a is this an acne t u led street' es Map iNumher P.1i"l ,Number
1 1 p l —.
1.3 Zoning Information: LJ Property Dimensions:
i
Zoning Dwrm - Proposed Use Lot Area(sq to Fiunlage I I) --
LS Building Setbacks(ft)
Fru;nt Yard Side Yards Rear Y:ud
Required Provided Required Provided ReyuueJ RutiJrJ
1.6 Water Supply: 1M.G IL r. 10, y sy) L7 Flood Zone Information: 1.8 Sewage Disposal System:
Zon Outside Flood Zone?
Public❑ Prolate❑ — Municipal ❑ On site disposal system ❑
Check it'yes❑
_ SECTI 3N 1: PROPERTY OWNERSHIPt
r.l O reef of Re ue i Prii 1 - Address lbr Service:
Si.n:nuie Telephune
SECTION 3: DESCRIP ION OF PROPOSED WORK (cheek all that apply)
New Ctmstructioni,C Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Allerahonf s) ❑ Addi(nrl ❑
Demolition ,❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description tit Proposed Work':
CC i
SECTION J: EST11MATED CONSTRUCTION COSTS
Estimated Cost :
Item t Labor and Materi dst Official Use Only
I. Building $ I. Building Permit Fee: $ Indicate ht,w fee is deter inined:
'. Electrical IS ❑Standard Ci(y/Town Application Fee
❑Total Project Coal'(Ilem 6) .x multiplier x _
3. Plumbing S '. Other Fees: $
4. Mechanical (HV \C) $ List:
5. Mechanical (Fire; S -----
Su ) reset„n) , Tut:d All Fees: S
('heck No. _Check Amount: Cash Amount
b Iotal Project Gust: 6U ❑ Paid in Full ❑OuisiandinV
t R:d:uue Uue:
SF.CTI N 5: C'ONSTRUC'•t'ION SERVIC'F.S _ _4
05.1 Licensed Construction Supervisor(C 'L)
G YCA Licrnse F\'1—iln�hrr�--L P:nllnralnun I).ua
Nalnr III C51." IlaWcr / 1."t CS I_Tt lie Isec hclow 1
_... / 'I\ c Uesrrl own ._
\dJ I'e+> ( nrC)Inr teJ RI IU i?.l N)ll Cu F1I
R Resuided Lv_' F-III\ Dll clew¢
Slenat it L�5 7 / / S1 Vanonry Only
J RC Ri+IJ:nnal Ruotlne
I'cicphunc wl Re+IJanual \\endue, and sldw�e
. SF Rc+ldcunal Soled Furl Hunul�e 11)LI_inrr
D Rr+Idrnlial Denwhoo. -
5.2 Registel (Iered lOnl�lmp cement Cunt clur
t° H
bO� � �a11 U11 `Illllher
HIC C )I11pany Name or III � al t am�fo o
c«
Addres, F.xpl atilm :ae
Signature 'relephune
SECTION 6: WORKERS' COMPS 14SATION INSURANCE .AFFIDAVIT(M.G.L.c. 152. § 2506))
Workers Compensation Insurance affidavit it, ust be completed and ..submitted with this application. Failure to pnn ode
this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached? Yes ......... ❑ No .... ❑
SECTION 7a: OWNER AUTHORIZATH N TO BE COMPLETED WHEN
OWNER'S AGE T O CONTRACTOR APPLIES FOR BUILDING PERMIT _
��[ Ll-e[� UCU U as Owner of the subject property hereby
to act on my behalf, in all marten
authorize '�
re!ativ to w•. I k :wthorized by this building rmit application.
Date
Si oat eu(Owner —�
SECTION 7b: OWNE r OR A THORIZED AGENT DECLARATION
I.
lre— � Ca C �llZ�s', as Owner or .Authorized Agent hereby declare
that the statements and information In the to egoing application :zee true and accurate. to the best of my knowledge an
behalf'. / �r
C tC/) Ce
Print Name
Date i
Signature of Owner or Authorized: ent
(Si ned under Ilte ams and enaltics ofperjury) NOTES: f
I. An Owner \chi obtains a building permi to do his/her own work,or an owner w'ho hires an u III egl.tered r,,noa nor
(not registered in the Home Impruveme t Contractor(HIC) Program). will not hate access to the urbitralwo
program or guaranty fund under M.G.L. •. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing tCS )can be found in 780(.•MR Regulations I IO.R6 and I 10 RS. respecotcly
When +ubstanital work is planned. prove a the information below:
Total flours area ISy. Ft.) (including garage. finished basement/atuo. darkso-ur porch I
Habitable room count
! (iross living area I Sy. Ft.)_ Number ut hedronms ------"-- - .
NumberoffrepLtces Numbcrotliali/h,uh+
Number of hathnalols Number of dccks/ pl Irrhe+ _.._
I'vpe of heaung system
Type of cooling system
"Total project Square Footage• may be ubsutwed for ''fond Project Cost"