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33 CROWDIS ST - BUILDING INSPECTION / O The Commonwealth of Massachusetts (��y �—L Board of Building Regulations and Standards Town of I Massachusetts State Building Code, 780 CMR, T"edition Building Dept 00 Building Permit Application To Construct, Repair, Renovate Or Demolish a #ISNWMS One- or Ilro-Furnill Duelling This Secti u-Por O(Ticial Us my Building Permit Numbe . Date pplied: Signature: ,n �5 C Budding Commissioner/Insl*ctor of Buil am SECTION Y SITE INFORMATION 1. ro erty Address: 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distnct Proposed Use Lot Area(sq R) Frontage(tt) 1.5 Building Setbacks(D) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' 2. wner oral: /r/r�.c a3 �s�DVy��S ST Name(Print) Address for Service: 97B 745 - �r46Z Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Brie Description of Proposed Work': 6 GC' .R N 9 'VC/1 .es�`✓rN' SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building S/S p © I. Building Permit Fee: S Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee /• Sm ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing S `S"0 a 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Total All Fees: S Suppression) Check No. _Check Amount: Cash Amount: 6. Total Project Cost: S f'7 0 0 O ❑ Paid in Full ❑Outstanding Balance Due: /19 r^ SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Constr o Supervisor(CSL) / n r�/vf!(= '� �i(?L r✓ �-/� License Number .puat n Date N.;Ime 101 L ! I r y �A :t CSL Type(,cc below) T- Description Addm U Unrestricted J up to 15,000 Cu. Ft.) R Restricted 1&2 Family Dwelling S nature /� N %lawnry Only RC Residential Rooting Covering TelephoneWS Residcnual Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residcnual Demolition 5.2 Registered Home Improvement Contractor(HIC) z� 2Z 9 H omp y Nam HIC Registrant Name Registration N mber �lre o 26Yocl;T` .vtY l Zo/'� Addrr3y� Ex ration Date Signature VV ss Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 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. Signature of Owner Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Silined under the gains and penalties ofperjury) 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 Mol access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I I O.RS,respectively. 2. When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch) Gross living area(Sq. FL) Habitable room count Number o(�replaces Number of bedrooms Number of bathrooms :`lumber of halfbaths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open 7. "Total Project Square Footage"may he substituted for 'Total Project Cost"