5 CEDARCREST RD - BUILDING PERMIT APP :Board
he Commonwealth of Massachusetts FOR
of Building Regulations and Standards MUNICIPALITY
Massaetts State Building Code, 780 CMR, 7aiedition USE
Building Permplication To Construct, Repair,Renovate.Or Demolish a Revised January
One-or Two-Family Dwelling 1, 2008
`aU This Section For Official Use Only
U` Building Permit Number: Date Applied: Q
Signature: J�/ 0>
Building Commissioner Inspector o uildings Date
SECTION 1:SITE INFORMATION
1.1 Property dress: I - 1.2 Assessors Map&Parcel Numbers
(yPt Ct.JC�✓ -t acl SG ke/yM
1.1 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
I
Required Provided Required Provided Required Provided
r
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner ofRect�r�d: �` c+ RCC I
CAtry. _ I :tcAn-e: 4 �w� oIt'2�o
-Name(Print) Address for Service:
G
Signature - - Telephone
SECTION 3:.DESCRIPTION OF PROPOSED WORle (check all that apply)'
Nex Ccnstructip. ❑ -Exis ng Build.:ig.❑ ch ^^cu�:cd ❑ ' .Repairs(s^, . ^I e iun(s) '�'' � o ❑ .
- .. _.
Demrililion ❑ AccessoryBld-0 Number of Units-_.-__ Other O Specify:_-. _
Brief Description of Proposed 3✓orl:': Q'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 5 Z 01. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑.Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) d Total All Fees: $
Check No. Check Amount: Cash Amount:
6,Total Project Cost: $ a I ) 5 D 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date.
Nkess
SL-Holder
4 l List CSL Type(see below) N -
A T e Description -
- U Unrestricted(up to 35,000 Cu.Ft.
ignature R Restricted 1&2 Family Dwelling
M Maso Onl
Telephone, lot RC Residential RoofingCovering
WS- Residential Window and Siding
- SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
2 Registered omeImprovement Contractor I
1�_�s a► 3q L L[ of 6 of
IC Compan Name or HIC Re istrant me t � Registration Number
Sa. cv ois3a
Ad e s l /J y/(0
5-b 5; -!q.0 02 94 Expiration Date
ignature - Telephone
SECTION 6:WORKERS, COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. g 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 .,........ W No........... ❑
SECTION 7a;:OWNER AUTHORIZATION TO BE�COMPLETED VaIE'N:. .
OWNER'S AGENT E CONTRACTOR APPLIES FORBUILDING,TERMIT
I, as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner - Date -
SECT ON 7b:.OWNER' OR AUTIIORIZED 4GENE DI CLARATION
} U+{ I r pip 1 as n vner hcmzed Ae tiecehv derl1tC
that thestatenrerits and infmninnon on the foregoing apph a[ion atetme and accurate, to tlrt b Sl of m;knowledee and
belialf
Print Natnc -
Signature of Owner or A or zed Agen - Date
(Signed under the pains and pena ties of er u -
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 and
Construction Supervisor Licensing(CSL)can be found in 780`CMR Regulations 110.R6 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below
Total floors 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 ofhalffbaths
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"