15 GREENLAWN - BUILDING INSPECTION y The ('o ntni nwealth 0I N1aSSadu1setts ---
Board ul Building Regulations and St:urdurds
F(IIt
%IJSSdrhuSC1fS Slate Building Code. 7511 UNIR. 7"'edition
13t i iIdin_ Perm \pplirati n To Construct. Repait-, Reno\ate Or DernolisIt :t
l hrr - oro Tit'o-Famih, Oil elling 1. ' rt',�•.
a ` Phis Seciion For Official Use Only
\� 4 ----1
'tel Building Permi Number: Date Applied: . 71, 0)
.� 4,T,7La,-*A
13wldmg Cuinnu+awned Inspecuu It Buddmgs Date _.
SECTION 1: SITE INFORMA TION
1.1 Property A dress: 1.2 Assessors Map & Parcel Numbers
1,I a is this an aczepted sheet:'y'es1 o :Map Number P:ucel Nwnhcr
1.3-2oning Information: - 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ti) Homage ill; --- ,!
1.5 Building Setbacks(ft)
FruYard Side Yards Rear Yaid
Required Provided Rcyuued Provided Required Pnnidcd
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: tl,.8Sewage Disposal System:
Zon _ Outside Flood ZoncPuhlic G Pndate❑ Check if yes❑ icipal ❑ On site disposal sys(em ❑
SECT[3N 2: PROPERTY OWNERSHIP'
2.1 wner'of Record: /0
` 1
lyO CRi � /-Old
N.uw,P ) Address[or Service' _
97
Si.n:. ur• Telephune I
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Cunstruction�l❑ Existing Building Owner-Occupied ❑ Repahs(s) ❑ Alteration(s) ❑ ,\dJitiim ❑
i
Demolition !❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Spealy:
Brief Description of Proposed Work':
SECTION J: ESTINIATED CONSTRUCTION COSTS
Estimated Cost
Item Official Use Only
(Lt,I_abur and Materi ds I
I. Building $ I. Building Permit Fee: Indicate how lie i.'s delenn1ncd j
❑Standard City/Town Application Fee
_. Electrical $
❑Total Project Cult' (Item 0) x multiplier s _
3. Plumbing 3 2. Other Fees: S
3. Mechanical (HVAC) S List: _
5. Mechanical (Fire!
S
Su) ressuml rotall :\II Fees: 5
'
_ Check NO. _Cheek Amount Cash \mount
b Total Project Cost
S 5 Ud ❑Paid In Full ❑ Outsumdin ,
E Balance Une:--
SEC'TI ON5: CONSTRUC"fION SERVICES
.5.1 Licensed Cuitstructimt Supr/r.isor 1(C"1.) /4 2
I ��� /L G Lirrnx Nunthrr 1`.+I n.aum t.ne
N.nnc at('SL I(older !' List CSL r.%pe ria•helur,
Wdrr+, C l lu'r+InrlrJ ni,to 1?,000('u PL 1
K Rru tdcd l&2Familk D„elhue — _7
.1wn:uul` \1:u„nn Only
L 6 d lJ] RC Re>tJemlal Kaoline ('u,ctin¢
rilopholle N'S Rr,idenl Wl too, ndo\\ .md Sidu�e
SF Re,ldcla .tl Solid Fuel I3nnun�lll,li_mrc In,l_il l.ui� i -7
D Re+iJawal Uruuihuu❑ _ _.____�
5.2 Rr tsterrd lam Im o%enient Cont • clor(HIC)
Registration V'umher
HIC C'dntpany Vilma or HIC •glstrm nine t_�
Addres+
� L
Signature Telephone
SECTION 6: WORKERS'COMPS SATION INSURANCE AFFIDAVIT (M.G.L. c. 152. S 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this applicationhadure to pro,tde
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... QJ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _
O 0 h as Owner of the subject property hereby
a ---"- "-
authorizr � to act on my behalf. in all m:ntet:+
relative to w•ot k authorized by this building rmit application.
Si nature al'Owner —�
SECTION 7b: OWNEIjOR AUTHORIZED AGENT CLA AT ON
I,
Ce- Lo �f C-- , as Owner or Authorized Agent herehy declare
that the statements and information on the fo egoin/g application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Dunj
Signature of Owner or Authorized:1'ent
(Signedunderthe pains and penalties of er'u ') NOTES: f
I. - An Owner who obtains a building permi to do hislher own work.or an ow�,,hoh,',r,, an unrect,tel J(nut registered in the Home Impruveme t Contractor(HIC) Program), will nocess to me mbiu"ation
program or guaranty fund under M.O.L. •. 11'_A. Other important information on the HIC' Program :end
Construction Supervisor Licensing (CSL)can be found in 730 CMR Regulation, 110.R6 and I I O.R5. re.+pec(oely.
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When ,ubstanual work is planned. v... a the informanon be[
nig enrage. finished basemenl/n mcs. decks t,r p,nrh,
Total floors area ISq. Ft. Habitable room count --
Numliving area ces Ft. Number of hedro�)ms ._.-------__--
Number of hrrplaces Number of h.tll/hash,
Number of hatmoonu
Number oY Jerks/ p,-hes
I'vpe of heating system - _-_Upcn --
Tcpe of cooling system - ---- ---i
3. "Toed Project Square Footage• may be ubsututed for "Total Project Cost'