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� The Commonwealth of Massachusetts
'' �,'{�s, ,� Board of Building Regulations and Standards t01b MAY 3 � C��F51
� '���ti 1� Massachusetts State Building Code,780 CMR Revised Mar 2011
,�,
' n Building Permit Application To Construct,Repair,Renovate Or Demolish a
U � One-or Two-Family Dwelling
nThis Section For Official Use Only
v" Building Permit Number: Date Applied:
� 5 31 l4
� Building Official(Print Name) Signature � Date
SECTION 1: SITE INFORMATION
1.1 P;opert�d��H �� y, I•2 Asses�o_r5s Map & Parcel Numbers
`� O �� 7
l.la Is this an accepted street?yes � no Map Number Parcel Number
13 nin Information: � � 1.4 Property D�im�sions: n
� �s ��
Zoning llistrict Proposed Use Lot Area(sq ft) Frontage ft)
1.5 Buildiug Setbacks(ft)
Front Yard - Side Yards Reaz Yard
Required Provided Required Provided Required Provided
N /�� � `� Fi G
].6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: I.8 Sewage Disposal System:
Pubiic L�� Private❑ 7one: _ Outside Flood Zone? Municipal yd-�n site disposal sys[em ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP�
21 Owner�of Rewrd:
n�,r�rzic (�. NRN.foni � Z�lY6C^ M• K14AIJ6N S' AL6�`t /y71� � /� 7 �
Name(Print) City,State,ZIP
� �1/ I�Cf-f W1� � q�7�—q� g—S61/ ���EEM�FNS�N27@
T/wZA/� . Cev2
No.and Street Telephone Email Address
SECTfON 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction ❑ Existing Building❑ Ow�ervOccupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition 0 Accessory Bldg. ❑ Number ofUnits Other ❑ SpeciCy:
Brief Description ofProposed WorkZ: I 3 D A( C �S
�I8'ni/1 . f�II�� C� r`lo�nrp puo�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
� Labor and Materials �
1.Building $ S(50 . O p 1. Building Permit Fee: $ Indicate how fee is determined: ;
2.Electrical $ � � Standard Ciry/Town Application Fee �
❑ Total Projec[Cost3 (Item 6)x multiplier x
3.Plumbing $ 2, O[her Fees: $
4.Mechanical (HVAC) $ � List:
5. Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑ paid in Full ❑ Ouutanding Batance Due:
f-�pC��-- TL� -�}�v 4'SC
" m�. �.Eo %� h �"1
SECTION 5: CONSTRUCTION SERVICES
• 5.1 Construction Su ervisor License CSL
P � )
� License Number Expira.tion Date
Name of CSL Holder �
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildin s u to 35,000 cu.ft.)
R Restricted 1&2 Famil Dwellin
CiTy/Towq State,ZIP � � M Maso
� RC Roofin Coverin
WS WindowaudSidin
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
52 Registered Home Improvement Contractor (HiC)
HIC Registration Number Expiration Date
F[IC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town,State,ZIP Tele hone
SECTION 6: WORKERS'COMPENSAT(ON 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 resWt in the denial ofthe lssuance ofthe building permit. .
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
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 J, R� cH fE R 0 �V �'� �/�
to act on my behalf, in all matters relative to work authorized by this building permit application.
,_ ,G- S�� . S� �/ / �
Print Owoer's Name(Electronic Signahue) Date
SECTION 76: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury tha�all of the infortnation
contained in this application is true and acwrate to the best of my knowledge and understanding. .
. ��/J�4� � q ---- S,3 i�/ �
Print Owner's or Authorized Ag Ys Name(Electronic Signature) Dare .
, NOTES:
, 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contrac[or
- (not registered in[he Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranry fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. o�v/oca Informa[ion on the Construdion Supervisor License can be found at www.mass. og v/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (i�cluding garage,finished basemenUattics,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 sys[em . Enclosed Ope�
3. "Total Projed Square Footage"may be substituted for"Total Projec[CosY'
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