50 WINTER ISLAND RD - BUILDING INSPECTION 41y�l a �l�"o Ll 3 - Hof Doo
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Cade, 780 CMR, 7'a edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- tau-FurrulYDivelling
is S ctiogF r Offici4i Use Only
Building Permit Nu le lied:
Signature: ' 0 c1
Building Commissto /Inspector of B d ta Date
SECT N I: SITE INFORMATION
1.1 Property Add eOss:�.^ der 5/ „� /� 1.2 Assess n Map d Parcel Numb*e D O
!t �/ 3
1.1 a Is this an accepted street:'yes no Map Number Parcel Number
1.3 Zo ng Information: 1.6 Property Dimensions:
Zoning District Proposed Use La Area(sq(1) Frontage(It)
1.5 Building Setbacks(R)
Frans Yard Side Yards Rea Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,s34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zona: _ Outside Flood Zone? Municipal ClOn site disposal s stem O
Public O Private O Check if a0 P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of C or : 0 / A„ ���O lv o 1Y,� 5
Name(Print) Address for Service:
— s` te
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) Addition Cl
Demolition O 1 Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proposed Work':
Dn 5 i i a� -' cti/✓ M d
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OAleld Use Only
labor and Materials)
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Costs(Item 6)x multiplier x
3 Plumbing S C . Z. Other Fees: S
4. Mechanical IH List:
S Vechanical (Fire S Total All Fees: S
Sun cession
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost. S 0 Paid in Full O Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) GS y5 73� /0
License Number Esprmton Date
Nyae ol'fSL HpIJc /'� �r Lw CSL Type(><v below)
.- Description
AJJress / r 4 !] O Unrestricted u to 55,000 Cu. A
( (/ Restricted 1!2 FamilyDwelling
Sian ur N Masonry Only
rO '1 0 wRC cssitddcmtaall Roaring Covering
SR
Telephne
Window and Siding
SF I Residential Solid Fuel Burning Appliance Instal latices
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Repsn ame Registration Number
l
Address Eapirstim Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. e. 152.S ISC(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 ARdavit Attached? Yea.......... O No.........._W
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTi b�:OWNE i OR AUTHORIZED AGENT DECLARATION
1 as Owner or Authorized Agent hereby declare
that the statements and in rmation on the krigoing application are true and accurate,to the best of my knowledge and
behalf. S� O
Print Name
Signature of Owner or Authorized Agent Date i
(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 am have access to the arbitration
program or guaranty fund under M.G.L. c. 102A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.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 Irving 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
I "Total Project Square Footage'may he.uhstitured for 'Total Project Cosy'