4 CEDARHILL RD - BUILDING INSPECTION (2) � `A � 5► �S
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The Commonwealth of Massachusetts �" T@ I #31 Rear Wae6mgton`Squa
State Board of Building Regulations and Y e-'---
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Massachusetts State Building Code ey ,� _ yr
780 CMR 'aeaeD� #31 Rear Washington Sgua
, (n' Salem,Mass.01970 '�
Application To Construct,Repair, Renovate,Change the use or Occupancy of,or .
Demolish any One or Two Family Dwel ling
CU -..
r This Section For Official use Only x
I6— Building Permit Number: / Date Issued:
Signature: , _ 1db dJ 147r--
Building Commissioner/Inspector of Buildings Date ofApplication
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.Ia Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zonin 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 ^�rovi
m
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal SfRem: 2.
Zone: _ Outside Flood Zone? " rTL
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal syst-c-i-a
SECTION 2: PROPERTY OWNERSHIP' r<
FR
2.l .O,yne�o 'I ,. FUfi1��6 �� ... mo
�� ; x
nt) Address for Service: •�
Signature Tele h ne
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
r' GG •�
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Official Use Only
(A) Building Construction Fee ' $ 1411000 -
Multiplier -
Total cost of construction (B) Fire Suppression/Alarm $2/1000
Shall Include all Labor+Materials (C)Estimated Total Cost of
Rounded off to the next Thousand Construction
Building Permit Fee
(A)+(B)x(C) - -
Total Cost of Fire Alarm/Sup $ Total Permit Fee: $ 0
Total Cost of Construction(C) I $
5ZKk - -1-0 Vnt
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7IZ 7 7
� License Number Expiration Date
Name of CSL-Holder
u/ �� �l'lt iI�O, List CSL Type(see below)
Address `''�� Tye Description
t'/!e !/7 U Unrestricted u to 35,000 Cu.Ft.
4 12- R Restricted 1&2 Family Dwelling
M Masonry Only
RC Residential Roofing Covering
Telephgpee > �i\/ \ WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Pone I prove nt Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
17�)d /Pik Li SCW ilJG_ .Src�l+�7 ���
A�'ddress
�� Ex`piratiorfD6te
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52.§ 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, !t p as Owner of the subject property hereby
authorize 6, to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature o wner Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
GC-t e- / yC/ // as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. / C
Print Name
Signature of Owner o Authorized A ent Date
(Signed under the pains and penalties of eju
NOTES:
I. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementiattics, 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"