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The Commonwealth of Massachusetts Pim i T
O Board of Building Regulations and Standards RECEIVED ED� CITY"
i Massachusetts State Building Code,780�I�i$PECTIONA jEAW;,
ar 4 i& 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
ro One-or Two-Family Dwelling INS APR 30 , A I b
I This Section For Official Use Only
`s J Building Permit Number: Date 'ed:
Luow
y �
Building Official(Print Name) rgaatttre Date
i% 41
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Ln 1.1 a Is this an accepted street?yes ✓' no Map Number Parcel Number
13 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(ft)
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 Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone? Munic4W❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSBTN
2 1 rt of i C- S'okm N
Same(Print) City,State,ZIP
No.and Sttt et Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied Cl Repa*s) ❑ 1 AlWation(s) W±LdLtiOn ❑
'd Demolition Cl Accessory Bldg.❑ Number of Units Other ❑ Specify:
S Brief Description of Proposed Work:
it C
N SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estiitem Labor and
Costs:
Offldal Use Only
1.Building $ 0DO -- 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 (HVAC) $ List:
5.Mocha nical (Fire $ Total All Fees:$
S ssion
h Check No. Check Amount: Cash Amount:
I C 17,4 6.Total Project Cost: $1&0, DQa " ❑Paid in Full ❑Outstanding Balance Due:
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D��Q� 15 - 35q
.y ,. i - ussEu.. D� STI EL.t-. l 5- 3 bo
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SECTION 5: CONSTRUCTION SERVICES
5.1 roustividon Supervise se(CSL} OS Dr �7O, i 7 A5
Risomt. License Number Expiration Dau
Na&e of CSL Holder
List CSL Type(see below)
No. %D 'Demolition
Description
nrestricted uildin to 35,000 cu.it
Ired ypc Restricted 1&2 Farm Dwellm
City State,
72 Masonry
Roofing Covering
window and S'
Solid Fuel Burring Appliances
Ji ow ONInsulation
Telephone Email address
i
5.2 Regiate B111-In 71A,e, a Imp ement Contractor(HIC)• J 3351D y
CGT IEC Registration Number Expiration
- Dilic
Company or C t Name
tY' c
No. 3 ZE 47-J --I fi�, -3 Q Email address
Ci ITo State J(J_/ Tel 7hoate
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.4 25C(6))
Workers Compensation Insurance affidavit must be completed and subtnitted with this application. Fohrre to provide
this affidavit will result in the denial of the Issuance of the building permitA
Signed Affidavit Attached? Yes..........0 No *-Rk
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT j
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.
!Tint Owner's Name(Electronic Signature) Dau
SECTION 7tr:OWNERt 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 . application is true accurate to the best of my knowledge and understanding.
er s or A=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 W 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.govlora Information on the Constiuction Supervisor License can be found at www.mass.gov/des
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 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"