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The Commonwealth of Massachusetts Pimz m IT)
O Board of Building Regulations and Standards RECEIVED CITY OF
n Massachusetts State Building Code,780 CMRINSPECTIONA jE
M2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling 1115 APR 301 A 4: 1 b
`l This Section For Official Use Only
`s J Building Permit Number: Date ed:
Lie~
j Building Official(Print Name) rgttature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
r
1.1 a Is this an accepted street?yes t•/' no Map Number Parcel Number
1.3 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
-- Front Yard Side Yards Rear Yard
I Required Provided Required Providod Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private❑ Zone: i Outside Flood Zone? Municipal O On site disposal system ❑
Cheese if es0
SECTION 2: PROPERTY OWNERSMIN
2 trot ICA pbrjz 'IsC, `Solem mrk--
Same
(Print) city,State,ZIP
I No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apPly)
New Construction O Existing Building O Owner-Occupied ❑ 1 Rcpaics(s) ❑ 1 Alteration(s) Wddition O
Demolition O Accessory Bldg.❑ Number of Units Other O Specify:
C Brief Description of Proposed Work-2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Ested
UL item Laborraandd MCaterials Official Use Only
1.Building $1W,QQd -- 1• B1ding Permit Fee:$ Indicate how fee is determined:
2.Electrical
$ C3 Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire S Total All Fees:S
S salon
n Check No. Check Amount: Cash Amount:
6.�CE 6.Total Project Cost: 1 $ 1p0. V�d r p Paid in Full 0 Outstanding Balance Due:
ua.�c.. MA�+c�,�, t,at� �t�y ✓
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SECTION 5: CONSTRUCTION SERVICES
5.1 CoBs7Mpervlso se(CSL) ^s � !V L,7 /�
77� 1 Li &se Number Expiration Date
NiFn of CSL Holder
List CSL Type(see below)
N� Type Desctipdon
U Umratrictod(Building to 33,000 cu.8.
R Restricted 1&2 Family Dwellingj
CityState,ZIP M Masomy
RC Roofing
WS window and Sidim
SFI Solid Fuel Burning Appliances
i OZ� I H Ii Insulation
Tel one Email addressD Demolition
i
5.2 Regis1e Ho elm ement Contractor(MC)•
h t✓ COP MC Registration Number Expiration
Compaery or C Re ' Name
r C
NoO 3 Email address
Ci State n Telephone•S
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 permi
Signed Affidavit Attached? Yes..........Cl No...........
Rk
SECTION?a: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 b;Wt in all matters relative to work authorized by this building permit application.
Print Owner's Name(Eloeftak Sipaturc) Date
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
i By entering my trate below,I hereby attest under the pains and penalties of perjury that all of the information
contained is this application is true p4d accurate to the best of my knowledge and understanding.
Lillf )•
Pa er s or A A t N (E is Signawe) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own wont,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(IUC)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 can be found at
www.mass.&ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor 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 halt7baths
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"