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The Commonwealth of Massachusetts INSPECT C LSD
Board of Building Regulations and Standards
[,q / Massachusetts State Building Code, 780 CMR Revised.Nor 2011
p� Building Permit Application To Construct, Repair, Renovate Or ffkla2 A 24
r k) One-or Tivo-Family Dwelling
llU; This Section For Official Us Onl
h-- Building Permit Number: Date.A lied€ l�
(r, Building Official(Print Name). - Signature- Date
V , SECTION 1:SITE INFORMATION'
1.1 Property Add;! : ( ! 1.2 Assessors Map& Parcel Numbers
,{ I.i 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 t1) Frontage(11)
QLS Building Setbacks(R)
(� Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Suppl I.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ovate❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes13
y . ple'UzUCTION2: PROPERTY OWNERSHIP)'
2.1 Owner1�r//l of Re ord. Va GiiJn�U
��me(Prn'yZ� • ell ell,,
City,State,ZIP
No.and Steel GLJz . Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Buildin �Namberof
ner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Acczssory Bldg.❑ Units_ Other ❑ Specify:
Brief Description of Proposed`York=: An
SECTION q: ESTIMA ED CONSTRUCTION COSTS
Item stimated Costs: OfRcial Use Only
-� (Labor and Materials)
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
Cl Standard CitylTown Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
J. Plumbing S P Qther Fees: S
d. Mechanical (HVAC) S List:
5. Mechanical (Fire 'rota) All Fees: S
Su ressiun)
Check No. Check Amount: Cash Amount:
6. Total Project Cust: S Paid in Full ❑Outstanding Balance Due:
101 Z'E5 �,�t��-r� c� u� r'3 tea_
P•C • — ltt: Zf, `t . CL'AlaSS'F- (S #s
•) ,.j J:� SECTION 5: CONSTRUCTION SERVICES
5.1 Cm action Su etvis r`L'y rise(CSL) S _ r)F 0/
License Number Expiration Date G r
_ _ 1
NamCofCSLII I,I-r "
�/ ' List CSL'fype(see below)
b /f n Type . . ' Description '
No. and Strec s
U Unrestricted(Buildings Lip to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town,Slate,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 1��Iome Impro vemen ntractor(HIC) //f 7 7/
' HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street /r w j Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION 1 NCE AFFIDAVIT,(M.G.L•c. 152.§ 2SC(6))
Workers Compensation Insurance affidavit m e completed and submitted with this application. Failure to provide
this affidavit will result in the denial qf!orrshuance of the building permit.
Signed Affidavit Attached? YYK....... ❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
I, as Owner of the subje rope , ereby authorize ✓��
t9 act on my a ,t a relative to work authorized by this building permit application.
Print Owner's Nane( ectronic Signature) Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name ow, reby ail t under the pains and penalties of perjury that all of the/inform. n
contained in Ili a licati true accurate to the best of my knowledge and understanding.
l
Print Owncr's or Authorized Agent's Name(Electronic Signature)
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 Fund under bLG.L.c. 142A. Other important information on the HIC Program can be found at
w-ww.mass.c,),Oea hirormation on the Construction Supervisor License can be found at www.mas.�rov'dns .
2. When substantial work is planned, provide the information below:
Total flour area(sq. ft.) 3 .(including garage, finished basernenVatlics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Typc Of heating system Number of decks/porches
Type of cooling system Enclosed Open
i. •Total Project Square Footage"may be substituted for'"rota) Project Cost"