28 CABOT ST - TBA-13-587 t .
The Commonwealth of Massachusetts Town of
\ Board of Building Regulations and Standards
a� Massachusetts State Budding Code, 780 CNIR. 7'a edition Budding Dept
Building Permit Application To Cons, ct. epa,r, Renovate Or Demolish a �
One- or Ttru- urruh nrl6ng
\;\,\ This Sects n For O cial Use Onl
1 y\YJI\ Budding Permit Num r D e Applied:
Signature:
Building Commissioner/1 " to of Buddta Date
SECTION : SI E INFORMATION
I.1 ProZ0 perty Addrns_ ST 1.2 Assessors Map i Parcel Numbers
C1�6o t
M Number Parcel Number
I.Ia Is this an acc ted street'!yes no W
tJ Zoning Information: 1.4 Property Dlmenslons:
Zoning District Proposed Use Lot Area(sq R) Frontage Ifl)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required I Provided Required Provided` .
1.6 Water Supply:(M.G.1.c.40,154) 1.7 Flood Zone Information: t.a Sowage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Cheek if
SECTION 2: PROPERTY OWNERSHIPt
2.t wnert of Record:
Sre,r,i St L6e9zi
Name(Print) Address for Service:
Sig ature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORKS(check a8 that apply)
New Construction O Existing Building O Owner.Occupied 0 Repain(s) Alteralion(s) O Addition O
Demolition O AecessoryBldg.O Number of Units_ Other O Specify:Brief Description of Proposed Workr:
r'�L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlclal Use Only
Item Labor and Materials
— I. Budding Permit Fee: f Indicate how fee is determined:
1. Budding f v vo
O Standard City/Town Application Fee
2 Electrical s
O Total Project Cost (ltem 6)x multiplier x
7 Plumbing S 2. Other Fees: f
4. Mechanical (HVAC) S List:
t Nechamcal (Fire f Total All Fees: f
Su ression
vo _ Check No. _Check Amount: Cash Amount:
A Total Project Cost. S ��� ❑Paid in Full ❑Outstanding Balance Due:
/`�e'Al ���� k.I,-
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 6(F-IF 06-3 G - Z6^ r
CiJ.At A«—, f3,C" (C, LiccmeNumber EvpuutionDuce
N,yoe ot('SL- HylJer Li.c CSL Type rn� 14,4, es_ (vecheluw) U
Address C )I&-S-I— Description
nMOResidential
Unrestncced u to 17,000 Cu. Ft
Si nature Restricted Ik2 FamilyDrellin
Residential RoofingCovering
Tclephons Residential Window and Sidin
Residential Solid Fuel Burning Appliance Installation
Demolition
S.�Reg1t1tred Horne Improvement Contractor(HIC)
/ 1 w .,..�>. 5 ��972Y
HJCCoffqmName or HIC Reg ist ant Nam r,t Registration umber
c9vr)S 2+> f> A-c�-P e Q�'Y A �� ✓Vl� l?<5�a— //.-U� </
/ilk• ) '� 978'2L„5-`sT Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL/ 2SC(6))
Workers Compensation Insurance aflidavil must be completed and submitted with this application. Failure to provide
this andsvil will result in the denial of the Issuance of the building permit.
Signed Allidavil Attached? Yes.......... @—, No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, (!e'r✓ s.L_4a&Lr , as Owner of the subject property hereby
authorize e F]- to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, CAA,d44 gJ-1C, w rS ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate, to the best of my knowledge and
behalf.
Print Name
Signatwe of Unmet or Authorized Agent Date
(Signed under the pains and penalties of
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unreJrespectively.
tor
(not registered in the Home Improvement Contractor(HIC)Program), will gg have access to the
program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Progra
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 1 10ly.
2. When substantial work is planned, provide the information below-
Total noon area(Sq. FL) (including garage, finished basement/anics,
Gross living area(Sq. Ft.) Habitable room count
.Number of fireplaces Number of bedrooms
Number of bathrooms Number of holfbaths '
Type ofheating system Number of decks/porches
Typeof cooling system Enclo,cd Open
( ' Total Project Square Footage"may he.uh,muted for"Total Project Cost"