4-6 CEDAR AVE - BPA-13-360 Y �
�I 7 fhe Commonwealth of Massachusetts
IWA y hoard otAlUilding Regulations and Standards CI IN OF
s ''y Mas.aachusctls State Building Code, 780 (WIR S \LI \I
r
Building Permit Application 'ro C'onsiruCt. Repair. Renovate Or Demolish a
Urro-or Tu u-f2onill• Du ellin,q
This Section For Olrcia se only
Building Permit Number: Data pplied; _
Building Official(Print Name) Signature )aw
SECTION 1:SITE INFORMATION-
1.1 Property A dress: c 1.2 Assessors Slap reel Numbers
��'�, E _
I.la Is this an acee ted street'?'ye no Map Number Parcel Number
1.3 Zoning Information, 1.4 Property Dimensions:
/oning District Proposed Use Litt Area(sq If) Frontage(II)
1.5 Building Setbacks((I)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Pricute❑ Zone: _ Outside Flood 2une1 Check if yesCl Municipal On site disposal system ❑
SECTION2. PROPERTY OWNERSHIP'
— Ow5#r'of RT-Vee or / nA
Wunc(Print) City.State,ZIP
9 /l //!� myAlly
No.and Street telephone Fmuil Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building O Owner-Occupied ❑ Repairs(s) O Alteration(s) ❑ 1 Addition ❑
Demolition O Accessory Bldg.❑ I Number of Units_ I Other O .Specify:
Brief Description of Proposed Work': II — o E
EX rIlle �.
y — Tyr L � G1dLL^
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item ft s' t) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how lee is determined:
'. Iilectrinl ❑Standard Cirffo%vn Application Fee
❑Total Project C'oila tItem 6)x multiplier
i .1 Plumbing S ,. Other Fees: S -
J. \kch.mieal ill\.\('1 S List:-- ----- -----__-fllr �b
j. \lahanir:d iFirc --
i Cuancisionl S Total .\IlFecs: S --
Check Vo. _( heck Amount: ('.ash \t1huml:
n Total Project Cus1: 0 Paid in Full 0 Outstanding ll.il:utce Due:
SE('PION S: CONS'I' UcrfON SERVICES
5.1 ('unstructiun Supervisor Licetue(('SLI /.J�C�33
I lceaso Number I'tl ration ),nv
N:m,enn'Sl. Hodder ..._.----
/� isl l'SI. f�pc
pe Description
N;;O Street
/ U 1 htrestricicJ I OuiWin s a pl iS,U110❑1, Il.l
It Restricted UL,2 I aind [Aw"in '.
Cirri I'ot,n.Slate.LII' U Alasun
RC' R,atfin Cuverin
µ'$ µ'indutv:mJ tiidin
SF Solid I-uul I)uming Appliuncas
141 Zf 17777 I Insulation
'I'ele hone I`mail❑Jdr,:' D Denlclition
5.2 Reginstered flume 1 provemen Cuntroctor(HIC) / y� roZ
f /— 9C ' —
GN O/✓!• IIIC'Regislr;niun Munher E.-pint!till Ualc
I lic C' n any m •t IIIC' Ite a tint
[:mall aJJRS!
7Z1/ 7?
City/Town.State ZIP rek hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atfdavit will result in the denial of the Issuanyt of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERINIT
Al
I, as Owner of the subject property,hereby authorize G
to act on my behalf,in all matters relative to work authorized by this building permit application.
d,Are Y �� P 1 7r Z
Date
n nl UINner's Nmne(Electronic Si nutue)
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 accurate to the best of my knowledge�^d understanding.
Print Owner's nr:\uthurircJ Ayent's Nnnw Ih.lcclrunlc Slgnawrel Wit:
No'rEs:
I. .\n Owner tthu'obtains a building permit to do his her utvn murk.ur an owner who hires an unregistered cuntmctur
trot registered in the Hume Improvement Contractor(HIC) Program).will rro have access to the arbitration
program ur guaranty fund under I.G.L. c. 142A. Other important information on the HIC Program can be found al
wttw n1.111 ot .,,.I Information on the Construction Supervisor License can be found at it i,1, t111 ;
2. \\'hen substantial work is planned, prutide the inlunnatiun below:
total floor area Isy. R.1 . ____.._I including garage. lmished basement attics.desks or porJi)
Gross lit ing urea 154. ll.l Habitable roots count
1 \umber of fireplaces .... .. . Number of bedrooms
Nonthcr of hathrooms — Number of half h;nlu
1')lie afheoting system \tunher ofdecks, porches
� I\pc tl cOPhllg jt 91♦'I11 1�11c loud __01 ell
1. `i.n.d !'role❑ Stillarc Fool Iota\ he •,,b,wwvd 6or..1'olol 'rojact Cost"