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< The omrnonwealth of Massachusetts
s 'i sry Board of Building Regtdations tmd Standard, REDEIY a OF
"( J Massachusetts State Building Code, 780 CM�NSPECTIONAI ERVICEr;I,rNI
•:�; " Revised Mar 2011
Building Permit Application 'fo Construct, Repair, Renovate C-NeN JiJ3 31 15
One-or Two-Family Divellrng Eet� JJUU�� LL JJ
This Section For Official Use Only
Building Permit Number: Date A plied:
Building OlHciul(Print Name) Signature pate
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
4 C3nrras C,r _
L I a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensimu-
Zoning District Proposed Usc Lot Area(sq Il) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rcar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (NLG.L c.d0,§54) 1.7 Flood Zone Information: I.8 Sewage Disposal System:
Public Er Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal 4drOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP!
2.1 Ownerp of Rcrnrd:
VIr(""( KaRaO SakX-YI �MA O lc'i1-0
Name(Print) City,State,ZIP
q (�rI r nP c C;r Q�R-5q4 C�c ��cl
No. and 31rect Telephone I?mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'- (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other M'Specify: cro 1 _
Briel'Descri ption ofProposcd Work: ��,>+LC_ -_ ��
a�s—t--r�-ur�zlC— caL���ej- C �,�,u l-- ------- — -------- ---- —
SECTION 4: ESTumxrED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and ,blateriuls) y
1. Building S I. Building Permit Fee:S Indicate how fee is determined:
7. Electrical $ ❑Standard Cityffown Application Fee
❑"Total Project Cost'(Item 6)x multiplier x_
3. Plumbing S 2. Other Fees:
4. Mechanical (I IVAC)
5. Mechanical (Fire
Suppression) 5 'fetal All Fees: S_
Check No. Check Amount: Cash
Amount-0 Paid in Full ❑Outstanding Balance Due:
S�7VT -7 rp 7 Mfk�C�ARt�A
(�2 -SMZ�Zb2
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
iw.y"
JA0"TJ3UML License Number Expiration Date
Name of CSL 1-lolder
i : Q F r ,r IJL List CSI..'I'ype(see below)
dIBI
No.and Street 'type Description
IJ Unrestricted(Buildings u2 to 35,000 cu. ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Rooting Covering
WS Window and Siding
Sk I Solid Fuel Burning Appliances
I Insulation
Telephone Email adJress D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or FIIC Registrant Name 'I
No.and Street
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
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
to 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: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
ucontained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) )ate
NOTES:
I. 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 find under IvI.G.L.c. 142A.Other important information on the HIC Program can be found at
www.ntass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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 Foolage"may be substituted for"Total Project Cost"