9 STATION RD - BUILDING PERMIT APP The Commonwealth of Massachusetts ( E C F ,r (7
CI OP
Board of Building Regulations and Standards iHSPE TICi, � IhV1CcS
+j Massachusetts State Building Code, 780 CMR Revised,Llar 2011
Building Permit Application To Construct, Repair, Renovate Or DemolisbO45 EC j Q P 2- 3
j} One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pied:: ?
t Building Official(Print Name) Sigu{e ate
SECTION 1:SITE INFORhIATION
1.1 ProIV=`
t3S F jLa 1.2 Assessors Map& Parcel Numbers
�l`1 L la Is this an accepted street? a no Map Number ` Parcel Number
—� 1.3 Zoning Information: 1.4 Property Dimensions;
Zuning District Proposed Use Lot Area(sq ill - Frontage(II) .. -
1.5 Building Setbacks(ft)
Front Yard Silo Yards - Rear Yard
Required , - Provided Required Provided I Required I Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sevrage Deposal System:'
Zone: Outside Flood Zone?
Public a Private D — Municipal O On site disposal system O
Check if es0 -
SECTION 2. PROP )ZTYOW.NER$HiPt
2.1 O(efern&4eehar r4t +p-n S IA vt M tc� d 19?6
ma(Print) City,State,ZIP
� Jk+ 4 oh f1 1713` 7/0 - ZD6) Z
No.and Stmot Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply),
New Construction Q Existing Building❑ Owner-Occupied O I Repairs(s) t f-I Alteration(s), ❑ Addition 0
Demolition O Accessory.Bldg.O Number of Units Other 13 Specify:
Brief Descri tion of Proposed Work':
+r;
SECTION-1:ESTUMATED CONSTRUCTION COSTS
item Estimated Costs: Offlelul Use Only
(Labor!aJnd Materials)
1, Building S 7 (pj p— 1. Building Permit Fee:$- Indicate how fee is determined:
?.Electrical $ ❑Standard Cityffown Application Fee
❑Total project Cose(item 6)s multiplier x
3. Plumbing S P ether Fees: S
4.1 lechanicai (tIVAC) $ List:
5.iMechaoical (Fire S
,Suression) Tota)All Fees:$
/( J ��� Check No._Check Amount: Cash Amount:
6.Total Project Cost: S t O Paid in Full Q Outstanding Balance Due:
. f�fa-t t�—p t c ) sra St! 12 17
SECTIONS: CONSTRUCTION SERVICES
5.1 Pastruction Supervisor License(CSL)
r C—'-� Q„
O,. I j C.-t? Sor, . License Number Expiration Date
Name of CSL holder
r^' �� List CSL Type(see below)
q I
No. and Street J 1�Y' �1 tI TYpr. - - Description
J^ C ��. VA A U Unrestricted(Buildingsug to 35,000 cu.It.
R I Restricted 1&2 Family Dwelling
City/Town,State,ZIP u I M
asom
RC I Routine Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
99, q 3 4 t I Insulation
Telephone Email address D Demolition
5.2 Registered Home fmproYt�e ent Contractor(HIC) /a G iM
rT'o t h ¢ ort
III�Up��py�y ne o� IC Registmn me 1ttC Registration Number Expiration Date
No.and Sued may^ �\O- 330 '��-^ 7�Y" 7 '13 7� Email address
Ci /Town State ZIP U Telephone t
SECTION b;WORKERS'COitiFENSATtON iNSiTRAiVCE:iFFfDAVfT(M.G,iL c.152 25C( },
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........... O
SECTION 7a;OWNER AUTHORIZATION TO BE COMPLETED.WHEAT
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize 1 r
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) _ Date
SECTION 7b;OWNER!OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pcijury that all of the information
containe nn this application is true and accurate to the best of my knowledge,and understanding.
1 � �f04 oN �,��, �' VCSL.(- 1 2- 7 -�s-
Print Owner's or Authorized 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.T4—A.Other im06ifdi t infoimaiion onionthe H1C'Prgfam t n liu fonrtd at" _-- "
www.mass.eov-'uua Information on the Construction Supervisor License can be found at www.mass.strvtdos
2. When substantial work is planned,provide the information below:
"total boor area(sq. ft.) 'x (including garage, finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number f fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks!porches
Type ofcooling System Enclosed Open
3. "foto! Project Square Footage"may be substituted i'or"Total Project Cost"