0005 GRISWOLD DRIVE BPA B-15-352 fi
CK'7 9 q 2t t 1'7 bo (17(" Era
The Commonwealth of Massachusetts Pt57-m IT
O Board of Building Regulations and Standards RECEIVED RCITY OF
Massachusetts State Building Code,780 CMRINSPECTIONA REevls 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling 7815 APR 301 A 4= I b
t t This Section For Official Use Only
Building Permit Number: Date ed:
A/
Budding Building Official(Print Name) igusture Date
41
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1 rr�
j 1.1 a Is this an accepted street?yes tom' no Map Number Pared Number
1.3 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(*)
--� Front Yard Side Yards Rear Yard
1 Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposed System:
Public D Private O Zone: — Outside Flood Zone? Municipal O On site disposal system O
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2 Mr'ofI e-, Vn�via- A)"'L SQ/l- )A.C
ame(Print) city,State,ZIP
I No.and Servet Telephone Email Address
E SECTION 3:DESCRIPTION OF PROPOSED WOR10(check alt that apply)
New Contraction O Existing Building O Owner-Occupied i3 1 Repairs(s) O 1 Alteration(s) Addition 0
�cl Demolition 13 Accessory Bldg.0 Number of Units I Other 0 Specify:
C C Brief Description of Proposed Worle:
C
SECTION 4:ESTIMATED CONSTRUCTION COSTS
item La)stimated Caoets:and Official Use Only
1.Building $/w, 006 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ O Standard City/Town Application Fee
O Total Project Cose(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
e Th6.Total Project Cost: $ 1p�, DOd r 17 Paid in Full O Outstanding Balance Due:
@�-Ito 6-t-,
6—A-"
.� I {.{ia"tZ.'C W 15-55
D+ �O>Z 1$^ 3 5 9
J 3 CaftSWQL,p De- lr I "6
_ l- Sn L_l..W El~� 15- 3 6 0
:� -� �� ! - _ '5_M SIL�o N � 1 e •3 5'�--
✓�! - -
15-3 '"� Ott.-�,M K� 15-35.8 _
f
SECTIONS: CONSTRUCTION SERVICES
5.1 ConstryVen Supervlso ae(CSL) OS q 17 �S
JQ f Lieeaee Number Expiration Date
N e of CSL Holder
List CSL Type(see below)
rr'-r Yy*,SAC. AIL
Nb. Type Description
rm1w �& U Uw atrictod(Buildings to 35,000 cu.tt.
R Resirieted lbt2 Family Dwelling
City State,ZIP M M i
RC Roofing
WS window and Sift
SF Solid Fuel Burning Appliances
li OZ� ON I Ioanlation
Telephone Email address • D Demolition
5.2 flonq Impirrement Contractor(RIC) 33rD _ y
J'1 Cor HIC Registration N?(um�(Lber Expiration Me
Iff company or C Re t Name
r C
No. S � �' f��-3U EmWaddma
C&Toin State Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L.c.15L§2SC(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 Issunnoe of the building print
Signed Affidavit Attached? Yes..........0 No...........
SECTION 7s: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 bebalt;in all matters relative to work authorized by this building permit application.
Print Owner's Name(Eleckanic Signature) Date
SECTION 7b:OWNERr OR AUTHORIZED AGENT DECLARATION
i By entering my name below,I hereby attest under the pains and penalties of perjury that all of the infotnoation
contained in ' application is Umpo accurate to the best of my knowledge and understanding.
` y I 1111�. '.
er s tx Auth A t N is 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 nM have access to the arbitration
program or guaranty fund under M.G.L.c.142A.Other important information on the I IIC Program can be found at
www.nvm. og v/oca Information on the Construction Supetvisor 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,docks or parch)
Gloss living area(sq.t3.) 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"