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BP APP 15-941 - 334 HIGHLAND AVENUE 5bc/ q, J�7o_ The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR��Sp RECEIb Q Building Permit Application To Construct, Repair, Renovate Or Demo4©Ii�3E ER V11� ked One-or Two-Family Dwelling August 13, 2013 �3 This Section For Official Use Only Building Permit Number: Date Applied: Signature: ( Building Commissioner/Inspector of Buildings Date - - n SECTION 1: SITE INFORMATION 1.] pr�gtyess: (� Assessors Map&Parcel Numbers FCI�II /t� 1.1a 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 OWNERSIiIPt [2.1 tom w r1.of ec d:1. or y / ? �/d C✓ U 'a e Name rint) _ Address for Service: 2Vl Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORW(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 : /! 49_ v �G SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ s ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ � 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ ! Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ Q(�, ❑Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) .7� Ol 7 / I r ZAI �� 1 License Number Expirati n Da Name of CSL-Holder List CSL Type(see below) tf AdN , I Type •Description Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling 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 Registerfed m Hotn�Im eent Contr ctLr(SIC) � zz Uri t��'d yof �ry (� Cv HIC Corn any Name or HIC R gistran a �(iz� Registration Number I . tiU, a �. 1 vt o+ Address ��n / ,21 &-31111{�'�� Expiration Date Signature Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) w 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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, J 4a �� z'4 � as Owner of the subject property hereby authorize /t1i r�� `S 1 r- to act on my behalf,in all matters relative to work authorized by this budding permi't pplication. Si ature of Owner Date SECTION 7h:OWNER' OR AUTHORIZED AGENT DECLARATION I, t ,- ,as Owner or Authorized Agent hereby declare that the statements and inform tion on the foregoing application are true and accurate,to the best of my knowledge and behalf. / ZIV/ Print Name Signature of Own i or Authorized Agent Date (Signed under the pains and penalties ofperjury) 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 110.115,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"