5 BOTTS CT - BUILDING JACKET t `4
a� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
J i$ SALL
Massachusetts State Building Code, 780 CMR I
`U Revised.11ur 011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Ohre-ur Trvu-Famil.v Dn ellin..q
This Section For Official Use nl
Building Permit Number: ate Applied.
Building Olticial(Print Name) Signature )ate
SECTION 1: SITE INFORMATION
I.I Property�Address: 1.2 Assessors Map& Parcel Numbers
.S/Jap G/
I.la Is this an accepted street?yes nc Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoningg Distr6t Proposed tJse Lot Area(sq 11) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.10,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Publirm� Private❑ Zone: _ Outside Flood-Lune? Municipal B�On site dispwul system ❑
Check if esGi�
SECTION2. PROPERTY OWNERSHIP'
2e1-Ownert of Record: �1
C d �i%���/
N;mte(Pont= _- City.State.
No.and Street relephone Fmuil Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition Accessory Bldg. ❑ Number of Units_ Other ❑ Spccity:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
item Estimated Costs: Official Use Only
(Labor and \late rials l y
1. Building $ eS 1 I. Building Permit Fee:$ Indicate how fee is determined:
'. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier _.e
3.. Plumbin5 S ?, Other Fees: S
J. \Ixhunical Ill\'ACI 5
<. .\Iechanical (Fire
.Su i rressionl $ Total All Fees:S __-----------------
Check No. _Check Amount: _ _ Cash Amount:
Total Project Cost: 8�� ❑ Paid in Full 11 Outstanding Balance Due:
i> r
SECTION 5: CONSTRUCTION SFRVICFS
5.1 Construction Supervisor License(CSL)
I License um I'spiralion Uotc
Name of CST. I lu der
_ -��----- Liu GSI,1)pe Iscc befoul
No. and Street L-05- hYPe Description
�/A��/• (. (hvestricled I Buildings u' to 35,000 cu. 11.)
�/�A�- R Restricted 1&2 Family Dwellin•
tyi ossn.. ta- C tc,7.IP M Mason
RC Rooting Covering
WS Window and Siding
C / /"�{dS�✓�l �• SF Solid Fuel Burning Appliances
fCrL ` t I Insulation
Telephone ('.mail address U I Demolition
5.2 Registered Home Improvement Contractor(HIC)
,�_,%' !%/G.O l /- �rNJ ``�i ✓t 111C' Rcgistrniun Number Expiration Dale
I IIS„C'mnpn u t•or"IC
li• islranl�ha. nc �.—
Yl"f
N50 d 'lr••t T— Email ad4tss
i / own.State, ZIP t I Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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
I, 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.
6lf-o.3- //
Print Owner s Name(Electronic Signature) Dute
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 accura the best of my knowledge and understanding.
Prin - ener's ame(Electronic Signature) Duty
NOTES:
I. :\n Owner who obtains a building permit to do hisiber own work,or an owner who hires an unregistered contractor
taut registered in the Home Improvement Contractor(HIC) Program),will trot have access to the arbitration
program or guaranty fund under%I.G.L. c. 142A.Other important information on the HIC Program can be found at
N�NNN% nio>..g;O% 0 .i Information on the Construction Supervisor License can be found at�%"kk,ma,:44 ..Ip.
2. When substantial work is planned, provide the information below:
Total floor area(sq. R.) (including garage, finished bascmcnt'attics,decks or porch)
Gross living area Isq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of lnalfbatlu
1')pcofhcatingSrstein . _ .--_-- _- - Number ofdecks, porches
. . .
I\pe of ao lino systenn Enclosed Open
3. "I otal Project Square Footage-may he substituted for"fond Project Cost"
9 TOE
OT
it
1,74 v lz
�. As4>- Ja-,�-�3Z