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The Commonwealth of Massachusetts Ptm i 7
O Board of Building Regulations and Standards REGEI ESD�RC1TY OF
Massachusetts State Building Code,780 CMRINSPECTIO�IA iEeeJW;v2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Fancily Dwelling IBIS APR 301A 4= I b
t This Section For Official Use only
'c J Building Permit Number: Dam 'ed:
J Building Official(Print Name) s7wature 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 ✓' no Map Number Parcel Number
1.3 Zoning Information: lA Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbaclts(ft)
_-- Front Yard Side Yards Rear Yard
i 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 O Private O Zo5e. i Outside Flood Zone? Municipal 0 On site disposal system O
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
zr'ofIt, n Id- pa'ojz sdC'.• solem ML.
r!e
Same(Print) City,State,22
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR10 ON&all that apply)
Now Construction 0 Existing Building 0 Owner-Occupied O 1 Rgx&s(s) 0 I Alterations) §f Addition 13
-0 Demolition 0 Accessory 814 0 Number of Units Other O Specify:
G s Brief Description of Proposed World:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
N item Estimated Costs: OI1leial Use Only
XA Labor and Materials
1.Building $1W,DUd 1• Building Permit Fee:$ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical S 0 Total Project Costc(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amotmt:
6.Total Project Cost: 1 $/&0. DSD 0 Paid in Fu(i 0 Outstanding Balance Due:
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SECTIONS: CONSTRUCTION SERVICES
5.1 Constryrflon 3nperviao ere(CSL) ^S 0-7 1 q t 7A "
R1&PM Lieease Number Expiration Date
Na&e of CSL Holder
^ 1 List CSL Type(see below)
.N � �( f�1 Type Description
U Umestrictod(Buildings to 35,000 cu.it
R Restricted 1&2 Family Dwelling
CityState,Zip M M i
RC Roofing Covering
WS Window and Sift
SF Solid Fuel Burring Appliances
LI P I tar •O,k I Insulation
Telephone Email address '1#00 D Demolition
5.2 Registe Home Imp ement Contractor(RIC) } 33 y/ j
CD r /
FUC Registration Number Expiration Dific
CompanyN C Re ' t Name
✓' c
No.072
—3� Email address
Ci /To State Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.G 152.4 2SC(6))
Workers Compensation Insurance affidavit mast be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building pannitg
Signed Affidavit Attached? Yes..........0 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 bebait,in all natters relative to work authorized by this building permit application
Print Owner's Name(Electronic Signahuz) Date
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my acme below,I hereby attest under the pains and penalties of perjury that all of the information
contained in ' application is true accumte to the best of my knowledge and understanding.
JVaq. ,oF5A AgEntl N (E ie 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 aM 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.gov/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 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. "Tocal Project Square Footage"may be substituted for"Total Project Cost"