B-17-1108 - 0035 1ST STREET - Building Permit 2l(� K 2� SZ7
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY a M SALE
Massachusetts State Building Code, 780 CMR Revised Mar 241'1,
Building Permit Application To Construct,Repair,Renovate Or Demolish a _
One-or Two-Family Dwelling rta
UV This Section For Official Use Only
Building Permit Number: - Date App�'!ce
A /
( Building Official(Print Name) Signature e
(` SECTION 1: SITE INFORMATION ;
1.1 Poe. Addres • 1.2 Assessors Map&Parcel Numbers
,4 l s.k . 'f�,e,Z_¢ #6
Lla Is this an accepted street?yes y no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Ow e 'ofR�rd: of At4 61f)y
r
Name(Prmt) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) OP Addition 0
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work 2: a. 1'1 + - W t
'1 L t i/1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ �� 1. Building Permit Fee: $ ndicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ SSUU ❑Total Project Cost(Item 6)x multiplier x
3.Plumbing $ )CQ Q 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
6.Total Project Cost: $ aq Check No. Check Amount: Cash Amount:
� ❑Paid in Full ❑Outstanding Balance Due:
11 J 1 (o M A t 1, ;D vm G ,c
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Licens (CSL) C9
/D/% U bfQ
h 9—fl
V/ � /, License Number 7 Expiration Date
Name of CSL Holder
% // ` List CSL Type(see below)
/� � �►e sA�C.1/tom. A I�61 No.and Street Type Description-
/� ��'/ / _ U Unrestricted(Buildings u to 35,000 cu.ft.)
AS pAA/ (� R Restricted 1&2 Family Dwelling
City/Town,State(ZIP _ M Masonry
AAb MWAA, RC Roofing Covering
WS Window and Siding
!' SF Solid Fuel Burning Appliances
/7►//►�II/kj�dy�cf.ej1&t b4,.4 I Insulation
Tel one Email address D Demolition
5�.22�Registered//H�oom�e Improvement Contractor(HIC) //?� 2 ,� /b �
HI T _ ^^' '� C R nos Na HIC Registratiioon/JNumber Expiration Date
HI Comp y Name or HIC Reg' ra t Name t,
;a-V_ ur'.d��-a� , CcuA �7"� ,(Cerid�/ �nyironAegkk-esAa S.C`e,).
and Str t I Email address
City/Town,State,ZIP Telephone
(� SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
Jt1 this affidavit will result in the denial of the Issua ce of the building permit.
a� Signed Affidavit Attached? Yes .......... G1 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 i;V tan n r� O U7,rwh7n.j
to"act on my behalf,in all afters relative to work authorized by this building permit application.
Pnn wner s Name(E ionic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
corjtai ed in this application,is true and accurate to the best of my knowledge and understanding.
�S"AAYUA I I / I vi n~'at HIT
Pr' wner's orl uthorized Agent's Name(Electronic Signature) bate
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. 142A.Other important information on the HIC Program can be found at
www.mass.Qov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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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