PER. APP 17-42 CONDO RENOVATIONS 21r7�
IThe Commonwealth > $rusetts
F
1 i E Board of Building' � 'SA E1v1
Massachusetts State Buildine Code,780 CMR
Revised Mai-2011
Building Permit Application To c tt#Telal"Golhe Or Demolish a
One-or Tivo Family Dwelling
This Section For Official Use Only
Building Permit'Number: Date A ied:
.r Buff ffnE Official(Print"Name) Signature Date
1
SECTION 1:SITE INFORMATION
1.1 Property Address: r ! 1.2 Assessors Map&Parcel Numbers
Z `1 1`1�rYt�1,'5 ; /0 ?�
1.1a Is this an accepted street?yes-4. no iviap 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 i Required Provided
1.6 Water Supply:(yl_G_L c.40,§54) 1.7 Flood Zone information: ` 1.8 Sewage Disposal System:
Public C1 Private❑ Zone- ^ Outside Flood Zone?
Check ifves0 Municipal❑ On sire disposal system 0
SECTIOit 2: PROPERTY OWNERSHIPt
1 2.1 O-.snert o;Record:
Name(Print) City,State,ZIP
2.17' ,c r '7— .fit /, k
No.and Street Telephone Email Address
(, SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
I New Construction❑ j Existing BuildinA, jOwner-Occupied ❑ + Repairs(s) ❑ Alteration(s) ❑ Addition C3
j Demolition ❑ ( Accessory Bldg. G' Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
i H/r S 7-
SECTION 4:ESTENLATED CONSTRUCTION COSTS
1 Estimated Costs: j
Item i (Labor and ivlaterials) I
Official Use Only !
1.Building jG� UG ( 1. Building Permit Fee:S Indicate how fee is determined: I
! f
2.Electrical S ❑Standard City/Town Application Fee
' i 2_C .�
❑Total Project Cost'(Item 6)x multiplier �� x O
3.Plumbing 1 S Z �;s�? G' ?_ Other Fees: S
4.Mechanical (HVAC) S j List:
S Riechanical (Fire
STotal All Fees:S
Suppression)
Check No. Chcck Amount: i y Z., Cash Amount:
6_Tota!Project Cost: 5 f Z t��'t!i ❑Paid in Full ❑ Outstanding Balance Due:
I/"Lc � Mf-\tt_C-x 1-b G ,C .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) !
1 1>)t:TT— I'��` R Y Liceicenn e '14q �� Ls Da i
License]Number Expiration Date
Name of CSL Holder ' J
�Aj f List CSL Type(see below)
Ke
v�
No.and Street Type Description
c' !� -7 6 U Unrestricted(Buildings u to 35,000 cu.ft.)
p I
1 1 Restricted 1&?Family Duelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
i WS Window and Siding
1
C` Sl' j Solid Fuel Burning kpplianccs 1
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
76& ZC �� w/7
HIC Registration Number Expiration Date
HIC Com ani Lame or HIC euisrrant fame
)E7 1/ P v /� i 'r�•�r y �c'Cµ�r:;Ccs.} .,.f_�a,�
N.�,And Street 7 Email address
j City/To«m,State;ZIP Telephone {
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Vlrorkers 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.
jSighed Affidavit Attached? Yes --------- No...........❑
SEC'T'ION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERIV11T
I.as Owner of the subject property;hereby authorize ✓ /` pal
to act on my behalf.in all matters relative to work authorized by this building permit application.
if9fit Owner's Name(Electronic Signature) Date
SECTION 7b:OWNTER' OR AUTHORIZED AGENT DECLARATION
i
By entering my name below,r hereby attest under the pains and penalties of perjury that all of the information
contained in'this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
TOTES:
I. An Owner who obtains a building permit to do hisller own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(MC)Program),will not have access to the arbitration
program or guaranty loud under MI .G.L.e. 142A_Other important information on the HIC Frog=can be found at
Information on the Construction Super-visor License can be found at
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including aaraue,finished basement%attics,decks or porch)
Gross living area(sq. ft_) Habitable room count
Number of fireplaces Number of bedrooms i
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 rootage"maybe substituted for-'Total Project Cost"