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I � The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,76 edition ReO EM visedJJ
Building Permit Application To Construct,Repair,Renovate Or Demolish a I, 2008
One-or Two-F ily elling
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1.1 Prop rty Addres : 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes_ o_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District, Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(it)
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❑
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2.1 //1 ain�g Record: e ,/l S �O �� `C �Z
Narde(Print) Address for Service:
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Signature Telephone
lTIOL�i 3 D 'IC r T(fiV '!fftrvPOS�E 01 ;(check all.that apply)
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:ESFIVIe)TDrCON$ UCTIQNCOSTS"
Estimated Costs:
Item Uffiet�I Use`Duly,
Labor and Materials
- - 1.Building $ 1 Bwj'dmg P,erf dt'Fee $ Indicate how fee is determined: -
❑SfaOdard Ciryfiown Applteatton Fee
2.Electrical $ T�tal'P[o3eat Gq f tem 6 x UIb her;, x
3.Plumbing $ 2 cOtf�erfFge
4.Mechanical (HVAC)
S.Mechanical (Fire
Suppression) Tota li*F'e�e 14
hcak No Chedk Amoupt: Cash Amount:
6.Total Project Cost: $ 3 y,:�)U_ p Pazd ih Full ❑Outstanding Balance Due:
o ry 5.-. ,Y Cyr tit i`rtwSM`V -.SL^Y`SYL�t'iS�'. £" ,n C`TtaNr n Crd ,
5.1_Licensed Construction Supervisor(CSL)
M MA
L a-i License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) y
.� /�.rtr' trl.t"i,y 0U rl �- U`P �SO.Qe/t Des'cri tiom
Address /p ,� (j U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature ` 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 Re istere H e I prove ent Contract� IC) /D (t ti
HI /Name or F C Reg y�nt me L` Registration Number
AddressG ' ' .�- G 7 74, Expiration Date
Signature / T—elJephone
SECTION 6 sWORTfETtSrUI�IPEISSTi( iN I1s1�SI3RANTk t1FFIDAUII
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...........❑
SL„CTI¢N'7a:O'WNER�[3�'iI�RIZATsIQNi�'t��EgC�; �'t'� ,y �''I�Tr��`
>pWNER?S,AGENT ORCt�N'1: 'CTOR APP \S' .OR BiIila 11V�,G RERfifiIT
1 7-4 Asr C-J rJ �/ J as Owner of the subject property hereby
authorize ,Li a to act on my behalf,in all matters
relative to work authorized by this buil g permit application. p 1
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Sr nature of Owner Date
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SEC1 IbN r7b,0, F ! 1 tkfxTT 73EL 4RATI1�1
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as Owner or Authorized Agent hereby declare
that the statements and informat�the foregoing application are true and accurate,to the best of my knowledge and
behalf.
L � .
Print Name v./ ® /^ _ G y /
Signature of Owner or Authorized Aggpt Date
Si ned under the aims and enalties of r'u
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 importantinformation 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"