9 STATION RD - BUILDING PERMIT APP (002) The Commonwealth ofMassachusetts RECEIVED
Board of Building Regulations and Standards INSPECTIONAL SWITYMIS
{( � Massachusetts State Building Code, 780 CMR p SALEM
D�Iti pw 1 RsvlseVI 2011
Building Permit Application To Construct, Repair, Renovate Or o a t�� L
One-or Two-Family Dwelling
This Section For.Offtcial Use 001
Building Permit Number: Date p lied€
42- 17
Building Official(Print Namaq). Signature- Date
I SECTION 1:SITE INFORMATION
I.I Property Address:� sioc+ U� I.2 Assessors�fap&Parcel Numbers
t il ! T ��.
1.to 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 tt) Frontage(It)
1.5 Suitding Setbacks(R)
Front Yard side Yards Rear Yard
Required Provided Required Provided. Rcqu)red Provided
1.6 Nater Su&6:(M.O.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: '
Zone: Outside Flood Zone?
Public Q Private O — Check Sf esQ Municipal Q On site disposal system Q
SECTION 2: PROPERTYOWNERSHIPt
2.1 Owners of Record:C� I YG.I-t M M 0 1170
me(Print) - City,State,ZIP
� 5 DV\ ila g716- arD to
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED IVORiC=(check all that apply)
New Construction Q Existing Building Q Owner-Occupled O 1 Repairso(s)A Alteration(s) CI Addition ❑
Demolition Q Accessory Bldg.13 Number of Units_ Other Q Specify-
Brief
pecify:
Briief'DeJscription f Proposetd2 Work-:
_ALL! - �- 3 t3 a ' 2 � I K .._}4-,.` � q_. ;U.,
SECTION 4:ESTIttNIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use only
Labor and iNlateriais)
I. Building S j g Qsj- 1. Building Permit Fee:$ Indicate how fee is determined:
�.Electric;d S Q Standard City/fawn Application Fee
Q Total Project Cose(item 6)x multiplier x
3.Phunbing S 2'.4 pother Fees: S
h
4. lccluvtical (HVAC) S List:
5.Mechmtical (Fire
t
Suppression) S Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ��"" OC Paid in Full 0 Outstanding Balance Due:
j Y;
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1>0 r)g 14� (1>J r r1-e + License Number Expiration Date
Nohl-c of CSL Ftolder
List CSL'fype(see below)
No. ;rad Street !!__ _ TYPa. " Description .
M c - V +2 )l to Rc1 �} i a U Unrestricted(Buildings tip to 35,000 cu.11.
R I Restricted I&2 Family Dwelling
City/fown,State,ZIP M I masom
RC I Roolin Coverin
WS I Window and Siding
SF Solid Fuel Burning Appliances
t I Insulation
Telephone Email address D Demolition
5.2 Registered Home Itgproveelmeennt Con�tractor(HIC) ( '2,(0g
I11 uu ear IIIC/F'Rrr""uOPa�r t N. e � IIIC Registration Number Expirud Date
t/p� ySSi-s3t 'tU nfL-L
No.mud Street
'j I`/AWS bv.y vh/)• y01`{,44`2sfJ1 Email address
Ci /Town State ZIP 0t5-tbF Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE'AFFIDAy1T(M.G.L.c.IS'L§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 Isivance of the building permit
Signed Affidavit Attached? Yes......... No...........O
SECTION 7a.OWNERAUTIIO. . TION TO BE COMPLETED.WHEN'
OWNER'S AGENTOR CONTRACTOILAPPLIES FOR BUILDING PERMIT.
1,as Owner of the subject property,hereby authorize /V M'e- �D�'y�
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signatum) Date
SECTION 7b: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.
POV-k A1("1✓14 "�- ( til, �l_c /'�_ -7- /s
Print Owucr'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 as owner who hires an unregistered contractor
(not registered in the Home_Improvement Contractor(HEC)Program);will rm have access to the arbitration
progiam ar guaranty funJ under M.G.L.c. 142A.cOlhcr importnnf hrnformufion on the HIC"Progiam v n be ou dot- --
www.mass.•_ov?oca Information on the Construction Supervisor License can be found at www.neass,=avldos
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq.tL) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Numberof decks/porches
Type orcooling system Enclosed Open
3. -Total Project Square Footage:"may be substituted tur"Total Project Cost"