56 FELT ST - BUILDING PERMIT APP (002) s +
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p The Commonwealth of Massachusetts
— Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 786 CMR, 7ie edition
Building D pt
Building Permit Application To Construct, Repair, Renovate Or Demolish a
00 One- or Tito-Family Dwelling �l�h
This Section For Official Use Only
Building Permit Num r: Date Applied: �S
Signature: b 4074,� V
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
L Prapert Addressc. 1.2 Assessors Map& Parcel Numbers
1.[a Is this an accepted street"yes_ no Map Number Panel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
t5
Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Requirod Providcd Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Name(Print) Address for Service:
9 —1
Signature felephane
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupie Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': < .f—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
-- - Labor and Materials
1. Building S nd O_ L Building Permit I": S Indicate how fee is determined:
2. Electrical S ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $Su pression) Total All Fees: S
o Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S p'^7 (�Q(7 .— ❑ Paid in Full O Outstanding Balance Due:
y�J t Q
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 0 9 yi—) (. -S 1 U—(p
7ZDO b b 1,J-5 License Number Expiration Date
N.4me of CSL- Helder p List CSL Type(see below)
• � (¢ � M T Description
AddsU Unrestricted(up to 35,000 Cu. Ft.)
t n R Restricted 1&2 Family Dwelling
Signature M Mason Onl
5!R RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Vistered Home Improvement Contractor(HIC)
at ti Y 1 r� Q .� 1
HIC Comp me or HIC Regisir am
Ne Registration Number
hs„Y
Address 4- 2- 3-- 1 o
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... O 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:/O+WNERt OR AUTHORIZED AGENT DECLARATION
1, �1- ,A� b—e b.p LY `-psv'T , as Owner or Authorized Agen hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf T'
1 ' �c7�0 by-riS
Print Name - e�
Signature of Owner o Authorize a Date —�
(Signed under the pains and penalties of perjury)
NOTES:
I. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.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. 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"