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The Commonwealth of Massachusetts ' W .
Board of Building Regulations and Standards + 3tt F
Massachusetts State Building Code,780 CMR 11a�11�� Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demdik 22 A tl� 5
One-or Two-Family Dwelling
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1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
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1.1 a 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(it)
1.5 Building Setbacks(f4)
Front Yard Side Yards Rear Yard
Required ProvidedRequired Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? municipal&�site al stem ❑
Public Pirvate❑ Check if �❑ P disposal system
SECTION 2: PROP%RTYOWNERSRIPt
2.1 Owner'of Record: f r\ q
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Nam11 e'1( etl City,State,ZIP
�`Id� 1rnrurd Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction O I Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ Addition E3
Demolition 91 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work"
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SECTION 4:ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ o v 1. Buildlog Permit Fee:$ Indicate hots he is determined:
❑Standard CitytTown Application Fee
2.Electrical $ p Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $
5.Mechanical (Five $ Total All Fees:$
S ression
GCS Aredk No. Check Amount: Cash Amount:
6.Total Project Cost: $ 7(p . ❑Paid in Fall ❑Outstanding Balance Due:
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S;ECLIONS ColvlaTRUMONbERVICBS
5.1 Construction Supervisor License(CSL) CS—tOp��i y tot
License Number ` on Date
Name of CSL Holder. '
List CSL Type(see below)
33 A(YANQ—,k Rd& Description
No.and Street Tyr - -
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ictedMadings up..:.. to 35,000 M.ft.
ted M2 Family Dwelling
City/Town,Stat Masonry
covering
and Siding
GG rr rrll •� uel Bunning Appliances
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Tel hone Email address tion
5.2 Registered Home Improvemen ontractor(HIC) «`i333 la-iAgk—l7
HIC Registration Number Expiration Date
HIC Com Name HIC Registrant Name
33 AM r� �f�SS�(,n�\-CU
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No.and Street �7p—�� 3� Email address
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Ci fro S ZIP Tel ane
SECMN 6:Vi'O3tI -COMPENSA1YON UOURANC.K AFFIDAVIT @LG.I.c:152.4 250(0)
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 AUTH ON TO U C01i4 RLETED WHEN
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` I,as Owner of the subject property,hereby authorize Zocli
to act on my behalf,in all matters relative to work authorized by#s building permit application.
Print Owner's Name(Electronic Sign ate
SECTION 7br 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 application is true and accurate to the best of my knowledge and understanding.
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Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NMS; ....
1. An Owner who obtains a building permit to do his/her own work,or an owner who hives an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fiord under M.G.L.c. 142A.Other important information on the HIC Program can be found at
MD .mass. og v/ora Information on the Construction Supervisor License can be found at M2M.mass.eov/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"
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