6 FAIRFIELD ST - BUILDING PERMIT APP (002) . 21S-2 CK -3
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The Commonwealth of Massachusetts V 14
CITY OF
Board of Building Regulations and Standards ,S EM
Massachusetts State Building Code,780 CMR 201b AUG 15 e 'se ar 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 lied:
.� �
Building Official(Print Name) Signature Date
1 SECTION 1: SITE INFORMATION
1.1 Property�gAddress 1.2 Assessors Map &Parcel Numbers
j b ,i f:e —
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
PublicZone: _ Outside Flood Zone? � .
Private❑ Municipal� C7n site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
?.enntit 1- lwin JysoZ 9r'L
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPT19>OF PROPOSED WORK'(check algimt apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Descri06o/nofProposed Work - a i.4'
d.Kl -ef,i!/
_ Srrf nr jC Y aye N l� ,Sr`f'c^.r c�'�%inn wYYrC
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 2T) 72 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 2 ypp ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 7POa 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 3 ��3,,' 13 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
4l -- e—,>
License Number Ex1firation Date
Name SL Holder
List CSL Type(see below) CJ
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Farinly Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
r��lr cJK SF Solid Fuel Burning Appliances
�7,f- 9/�� l/Cr l'Zor/.<.p I Insulation
Telephone ! Email address D Demolition
5.2/RC)
Registered Home Improvement Contractor(HI
c:qt&}%zky-/ St- HIC Registration Number Expiration Date
HIC Company Ne or C Registrant e
S 6 N. v-hna. f
and Street Email address
� t po F2�923 77'1-
City/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 .......... No ...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIESS FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize airzrt &0
4e4 i
to ac�t on my behalf,in all matters relative to work authorized by this building pe 't application.
a
Print Owner's Name(Electronic Signature) I Date
SECTION 7b: OWNER'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 application is true and accurate to the best of my knowledge and understanding.
'nt Owner's or Amhorized Agent's Name(Electronic 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 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
1y .ivass. otg �/oca Information on the Construction 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"maybe substituted for"Total Project Cost"
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All nsdimensions size designations This is an original design and must Designed: 5/3/2016
given are subject to verification on not be released or copied unless Printed:7/19/2016
job site and adjustment to fit job 2020 applicable fee has been paid or job
conditio . 1 order. placed.
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1--29 "--} ---27"---=-�371. 26 Sqft Flootlng
,�-77b' „� TILE 1 at Floor Half Bath
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-46rz' 18"63
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TILE 2nd Floor Bath
130 Sqft for Shower Enclosure
24 Linear Feet for Bull Nose for Shower
46 Sqft for Bathroom Flooding _
All dimensions size designations This is an original design and must Designed:5/3/2016
given are subject to verification on not be released or copied unless Printed:8/2/2016 j
job site and adjustment to fit job202 applicable fee has been paid or job
conditions. order placed. �.
I
Heenan Bath All Drawing#: 7 I No Scale.1