28 BROAD ST - BUILDING INSPECTION (2) Q The Commonwealth of Massachusetts iPECT« � r
6' Q Board of Building Regulations and Standards q ,C,I�IppT'gY OF
`Q Massachusetts State Building Code,780 CMR __,b ��N 22 R�vi(kAITr2011
t j��u►
Building Permit Application To Construct, Repair,Renovate Or emolish a
_ One-or Two-Family Dwelling
This Section For Offigi I Use Only
Building Permit Number: I Date Applied:
Building Official(Print Name) Signature Date
21 ^ Z _ SECTION 1: SITE INFORMATION
1.1 P37 Ad ess: 1.2 Assessors Map&Parcel Numbers
Lla Is this an accepted street?yeses_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(8)
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'
2.1 Owner'of Record:
(?tjnrn'-P ! 'A L nnn, S,f
Name(Print) City,State,ZIP
r1 dS ee[grn�d
No.and Str Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s)j( Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
t/ o deL
0 Gk ram, �1-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ U �� _ 1. Building Permit Fee:$ Indicate how fee is determined:
$ ❑Standard City/Town Application Fee
2.Electrical
- OT/ ❑Total Project Cost"(Item 6)x multiplier x
3.Plumbing $ dD 2. Other Fees: $
4.Mechanical (FIVAC) $ List: c X -
5.Mechanical (Fire $
Suppression) Total All Fees: $
U Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ / 9��d0 ❑Paid in Full ❑ Outstanding Balance Due:
�- h
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 7 V19( i)_E.t '
Se c — U%L,r-,, License Number Expiration Date Name of CSL Holder w � List CSL Type(we below)
3
No.and Street Type Description
/� 1 U Unrestricted uildin a to 35,000 cu.ft.
L Lit r r r' 0 5 �J R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Masonry
RC Roofing Coveting
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D I Demolition
5.2 Registered a
istered Home Improvement Contractor(HIC) 4133 ?-13-1
rf VQC LEA— HIC Registration Number Expiration Date
HIC Company Name or C Registrant Name
23 �(c-. = C=mm ynti11GCW 'tLVeSL,A-e 6oMCAr+-n7f
No.and Street �� Email address
J-� -X" e( o( Mnr 417-90S7SFr/
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
I,as Owner of the subject property,hereby authorize SC-AW
Qr—
to acctt on my behalf,in all matters relative to work authorized by this bum ding permit application.
l �slr1 OpRnm (c "ZL— I (a
Print Owner's Name(Electronic Si a[ure) 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
contained in this pli /
tin is a and accurate ebest of my knowledge and understanding.
( 0 2�—/�
Print Owner's o Agents Name(Electronic Signature) Date
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. oe, v/oca.Information on the Construction Supervisor License can be found at www.mass.wv/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'