17 WILLSON ST - BUILDING INSPECTION (2) cK 48 `I 3
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
'y % Massachusetts State BuildingCode,780 CMR,7`"ed,t
Iro�ECT ONEAL SIV ILITv
- - Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised January
One- or Two-Family Dwelling mAQ �.gQQB
This Section For Official Use Only " ,...
^� Building Permit Number: 2 Date Applied:
r �t 'Signature:
Building Commissioner/Inspector of Buildings e Date
{ n SECTION 1: SITE INFORMATION
ll I 1.1 Property Address• 1.2 Assessors Map&Parcel Numbers
-- /7 u,�/Ison 5 f
1 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❑ On site disposal system ❑
Check if yes❑
SECTION 2:`PROPERTY OWNERSHIP'
- 2.1 Ow er of R cord:
- U cf �7—�>vr�/G✓1
Name(Print) Address for Service:
7yS
Signature - Telephone -
' 'SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:Labor and Materials Official Use Onl
'
y :-
I. Building $ 1 Building Permit Fee: $ Indicate how fee is determined:
❑,Standard:City/Town Application Fee `l -
2.Electrical $ ❑Total Project Costs(Item 6)x multiplier x f
3.Plumbing $ .2 Other Fee $
4. Mechanical (HVAC) $
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No Check Amount Cash Amount:
6. Total Project Cost: $ jd6 G ❑Paid in FuIL ❑Outstanding Balance Due:
Slmv i a��
SECTION 5: CONSTRUCTION SERVICES,
5.1 Licensed Construction Supervisor(CSL)
4 C '` 4 r, S �� (ice License Number Expiration Date
Name o/ [ t f CSL-Holder .
i/,U !'� �AA List CSL Type(see below) (�
✓ , /_(/�`
Address' r Type Description
•la U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwellin
Signatuc{re� �y G M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered�7 Inprov mentContractor(HIC)
HIC Ace
Company Name or HIC Registrant Name C Registrations
A ress
Expiration ate
Signature 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...........❑
SECTION Tat OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
" I, G e as Owner of the subject property hereby
authorize C to act on my behalf,in all matters
relative to work author ed b, this building permit application.
Si nature of O Date
SECTION 7b:.OWNERr OR'AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. l
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury
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 M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,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"may be substituted for"Total Project Cost"