3 GRISWOLD DRIVE - B- 15-351Cr, 79L4 1-7bO C17G°°En,
The Commonwealth of Massachusetts PEKrn-IT)
O
CITY OF
Board of Building Regulations and Standards RECEI ED
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K`P Massachusetts State Building Code,780 CMRINSPECTIONA ER
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etnsed ar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling R 30 A 4, Ib
t This Section For Official Use Only
t/Building Permit Number: Date pied:g
Building Official(Print Name) Signature V Date
SECTION 1:SITE INFORMATION
V7 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
IV , 1.1 a is this an accepted street?yes V' no Map Number Parcel Number
13 Zoning Information: 1A Property Dimensions:
1 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:
Zone: _ Outside Flood Zone?
Municipal On site disposal stem Public Private Check if yes
P P system
SECTION 2: PROPERTY OWNERSHIP[
2 fir!ert of R d:aC'
ame(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building Owner-Occupied I Repairs(s) 1 Alteration(s) Addition 13
d Demolition Accessory Bldg. 1 Number of Units_ Other Specify:
C Brief Description of Proposed Work':
N
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Official Use OnlyLaborandMaterials
1.Building 16W, DOI) 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical
Standard City/Town Application Fee
Total Project Cost(Item 6)x multiplier x
3.Plumbing 2. Other Fees: $
4.Mechanical (BVAC) $ List:
5.Mechanical (Fire
Total All Fees:$
Suppression)
Check No._Check Amount: Cash Amount:
I bKE Y 6.Total Project Cost: $J&0. (/Qi/Paid in Full Outstanding Balance Due:
J3 C Ktswpvp 17L 15s3 1 - _ ` y STiLL_WE.L-L- 15- 3bOS5-3_S2 i ussEu Dt_ 1
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SECTION 5: CONSTRUCTION SERVICES
5.1 Cons on Superviso se(CSL) C U-7 *'?V 1.7
License Number Expiration Date
Na&e of CSL Holder
ulL/
L rt-y- t C.. f/
7 .L List CSL Type(see below)
No. t J M
Type Description
J /ten Q Ii U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
Cityrro State,ZIP M Masomy
RC Roofing Covering
WS Window and Siding
tt
SF Solid Fuel Burning Appliances
G 'ON I Insulation
Telephone Email address a N . H1 I D I Demolition
5.2 Register-}Home Improvvement Contractor(HIC) 1 a92SIO y/
erh / Q't }6C htm Corp HIC Registration Number Expiration Date
MC—Company or JC Regis t Name
c
No. St:
V,J.yy 3 Email address
VA 0Ci /Town State,Z Tel hone
SECTION 6:WORKERS'COMPENSATION 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 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
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in t i application is true Ad accurate to the best of my knowledge and understanding.
6
Pri er s or Auth rized A nt' N ne(EIW&Onic Signature) Date
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 no have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) including garage,finished basementlattics,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"