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ga The Commonwealth of Massachusetts
Board of Building Regulations and Standards 101b SE -2`711'
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Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Appl
Building Oficial(Print Name) Signature. Date
' SECTION 1:SITE INFORMATION
LnLl Property Address: (� 1.2 Assessors Map&Parcel Numbers
1 ?;21tF1\,2LWn VCQ -til �a-8
{� I.la Is this an accepted street?yes no Map um er Parcel Number
I1.3 Zoning Information: 1.4 PropertyDimensions:
p2 D, i.� 3
Zoning District Proposed Use Lot Area(sq ft) Frontage(fin
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'-(check all that apply)
New Construction ❑ Existing Building OKI Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: 44-V;}C.
Brief Description of Proposed Work':
Y�P S\YT N
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate.how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ -❑ s
Total (Item 6)xmultiplier .. x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ "'1conList:
5.Mechanical (Fire S -
-Suppression) Total All Fees:$
Check No Check Amount: Cash Amount:
6.Total Project Cost: $ VU V ❑Paid in Full ❑ Outstanding Balance Due:
' VIZ Mat (.gyp 'MG -C ,
o �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) iql C-Q
\ License umber Expiratia bate /
Name of CSL Hdider
C Linc CSL Type(set below)Vr\.4 '
lw� 5��1C + Type . . . . Description.
No,and Street
U RestriUngescted
1 2 Faris el 35.000 cu,ft.
R Reatritted 18t2 Pamil Dwelling!
Ciry![own, u,Z[p M MMBU
RC Roofing Covering
WS Window and Sidin
(,,, , SF Solid Fuel Burning Appliances
I Insulation
TeI hoot Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
RIC Rcgiauation Number Expiration Date
NIC Company Name or RIC Registrant Name
No.and Street Email addross
C' (Town State ZXP Telerbone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFii}AVII'(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..........P" No...........❑
SECTION 7a:OWNER AUTHORIZATION TO)IE COMPLETED WHEN
:OWNER'S AGENT OR CONTRACTOR APPLIES FORRUILDING VERMIT
1,as Owner of the subject proporry,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Not Owner's Name(Electronic Signmure) Date
SECTION 7b:OWNER'OR AUTHORIZEIT AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this a lication is�truee d ac to to the best of my knowWge and understanding.
V ' q I j/ 10
Print OwAuthorized Agent's Name(Electronic Signature) Date
NOTES:
I- 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 Bgt 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
wwwgtagh,gpv, lova Information on the Construction Supervisor License can be found at www�l pg
2, When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
(h'oss living arca(sq.'R.) habitable room count
Number of fireplaces Number of bedrooms
Number efbathrooms Number of ball/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"
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HTC Registrant Name
No.and Street Email address
Ci /Town,State,ZIP Telephone
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 .......... Er'� No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
.OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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: OWNEW 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 this a lication is true 4nd ac ate to the best of my knowledge and understanding.
�( a 1 11 to
Print Own r Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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 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.eov/oca Information on the Construction Supervisor License can be found at www.mass. og v/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 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"