222 CANAL ST - BUILDING INSPECTION - - - - - - - - - - C.-Y- 2-1(,a I t ( Z
The Commonwealth of Massachusetts
t Board of Building Regulations and Standards
Massachusetts State Building Code, 780 Qfti VED
U— Building Permit Application To Construct, Rep!MMeRfavl`atei&gem�iM%
(� One-or Two-Family Dwelling Rev. Sept 2014
O' This Section For Officialill Q0 Wy
Building Permit Number: Date Ap to .
IJ
6mlvlo Win-,
1.
1 Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
aaa. �'�,rral�Yte..�
L l 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 ft) Frontage(ft)
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, 454) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public ❑ Private❑ Check if yes❑ p p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
-q':�a.e.c-�\c
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': r/ +o t a cry-
S ta+ ti el r-S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ g 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire Suppression)
$ Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 1 g ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
e ` CS -c55�733 `� ara r� V
ht< 1s-I OJAe 2 �rZV' License Number Expiration Date
NameofCSLHolder
1 15" tQ O! S ee List CSL Type(see below)
No. and Street V Type Description
U Unrestricted(Buildings u to 35,000 cu. ft.)1 q�
J_ R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
<YN-741 -64a1f rl!c) �t�,(Q KCS.(Lnn I Insulation
Telephone //�E'm'"'a51address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 16 J loOg 6 a& x CP
A+ ASQcilces + T✓tG HIC Registration Number Expiration Date
HIC Company ame or H[ Regis[r�{t Name
1 S �D<`�1, �ex�C C`Zl1fZ��Q� �., SPI�t1lCPS.<0
No and Street Email address
4a\2 VVI YYI GI 619-7 0 G") - I L(1-64a`4
City/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 4 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 Issuapce of the building permit.
Signed Affidavit Attached? Yes .......... IV No ...... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property, hereby authorize e_r�r iS F7 �Vl�f OlL��
to act on my behalf, in all matters relative to work authorized by this building permit application.
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442 \�,�-01.� v S-e2 Ca pl-kalcs 2 - [;� l
Print Owner's Name(Electr nic Signature) 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 application is true and accurat wVe best of my knowledge and understanding.
h _—
Print Owner's or Authorized"Agent's arnC(Electronic Signatur 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/d s
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 hal f/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"