18 BROAD ST - BUILDING INSPECTION ti
The ('onmwmsealth of Massachusetts
i Board of Building Regulations and Standards F(IR
r ,i, � ?Il'NI('ll'.\I.I'll
( ! �� Massachusetts State Building Code, 780('MR. 7 edition I Sl
) i
(� Building Permit Application To Construct. Repair. Renovate Or Demolish a Rci ocd hmoaru
One- or Ttru-Furnih Dtrellin,i: _nn)'
This Section For Official Use Only
KYD Building Permit Nt tbee Date Applied:
atuc
Building Conunissim Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property :liddress• 1.2 Assessors Map & Parcel Numbers ,
L la Is this an accepted street? yes no_ Map Number Parcel N'uwhei
1.3 Zoning Information: LJ Property Dimensions: —
"/_onaw District Pn:po ed Use _ Lot Area isy ili Front ail
_ _—_—
LS Building Setbacks ffq
j Front Yard Side Yards Rear Yard
! Rryuired Provided Rcyuired Provided RcyuireJ PrucidaJ __-�
— ..
Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
'Zone: _ Outside Flood"Zone'.' Munici �I ❑ On site disjxisal system ❑ �
Puhlic ❑ Private❑ P'
Check if
SECTION 2: PROPEPTY OWNERSHIPt —I
2 ( Ow•nert of Record:
�'1� R11YS+t fQr�N DA -- _Z� OA p_�57�--
! �anv IF O Address for Service
Sienatura. � Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
j Nev, Construction ❑ Existing Building Id Owner-Occupied ❑ Repairs(s) ❑ Alterdtion(s) ❑ Additwn ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other lid Specify: IV60F 990kIAL
BricfDescriptionotProposedWorkz:�.9_A E nLD ��iiMRL ctRENEN/ !V/T����✓
I --�n��airl✓lea—ct� Reo F.------- - — - —J --
- ---- ------ . ---- ---- -- j
I{ I
SECTION 4: ESTIMATED CONSTRUCTION COSTS 7
Estimated Costs:
Item Official Use Only
j (Labor:nd Materials) _
I. Building 'S '0�� OQ I. Building Permit Fee: $ Indicate haw fee is Jercnninrd:
❑ Standard City/Town .Application Fee
2. Electrical ❑Total Project Costa (Item 6) x multiplier x
3. Plumbing y 2. Other Fees: .h
4. Mechanical (HVAC) List:
S --- ----
�. Mechanical (Fire S --
Su ression) _ Total All Fees: S
Check No. Check Amount Cash
I o. Total Project Cost: 'has' Bd0• ❑ Paid in Full ❑ Outstanding Balance Due:____-
j
y
17a
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
L ylly S. Klbily - Lt,cnse Number Ispienion Date
Name of CSL- Holder
_I_(._0,TV0R l� 7 s� / l(�y .�ynA List CSI_T)'pc(see helowl _
\ddress G -1Yr T• c Ucsrn loon
'✓ — C Unresuirtrd tuito i5.(N10 Cu. ft.t
R Resl,i.00d I&'_ Family Doelline
Signwurr 99 .\1 N1:uonn' Only
RC Rrsidrntial i2ouling Co,enne
Telephone \N'S I Residential Wlndum .uul Siding. -
SF R,,idonti:d Solid fuel Burn..._ \ pl i:m.. In,t.ill.it,
D Reeidential Deniohuon
5.2 Registered home Improvement Contractor (HIC) , 7� V
%//✓ R, KinW; --
[Ait Company Name or 111C Registrmu Nance Registration Number, ,
-\T � KClCy .-- o ZNC r /q g
Address p ✓ -+:/
_ t0S A A 111970 Expiration Date
nature Telepbo,n9,7X 7# f1,r -- --
Y �R 7/ Ti7// . _t
SE TION : W RKE OMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with ;his application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit. -
Signed Affidavit Attached'? Yes .......... 01' No .......... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
I�OWNER' AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
_-- _-- --- -' as Owner of the subject pr,,pei ly hereby
authorize __. __ to act on my behalf, in all matters
let to work authori by th g Permit application.
natureot Owre ._D:ue._—__._—_
SECTION 7b: OWNER' OR AUTHORIZED AGENT DF,CLARATION
r, as Owner or Author ized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Pot,
.Signature of Owner or A rzed Agent — 7 —__— ---- Date
.Signature
fined under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains it building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Irncr.;vzracnt Contractor (HIC) Program), will nu.t hsc'e access to the arbitration
program or guaranty fund under M.G.L. c. t42A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL)can be found in 780 C MR Regulations 110.R6 and 1 10.R5. respectively.
'. Whan substantial work is pla:wed, provide the information below:
Total flours area (Sq. Ft.) (including garage, finished basement/attics, decks or porch(
Gross living sea iSq. Ft.) _ Habitable room count
Number of fireplaces _ Number of bedrooms .
Nam^er of h;nhrooms __ Number of haWb;ohs -- __--_-
fype of heating System Number of deck-,/ poichc.,
Type of cooiing system -. --- Enclosed - - Open
3. "Total Project Square Footage- may be substituted for "Total Project Cost-