8 8 1-2 CENTER ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
Board of Building Regulations and StandardsA/.
Massachusetts State Building Code, 7,40 C'MR, 7"edition
Revised
y
Building Permit Application To Construct, Repair, Renovate Or Demolis
(bee-or Two-Family Dwelling
This Section For Official Use Only
Building Permit N ber: 4 Date Applied:::
Signature: v 1-tz / ///O/
Building Commissioner/Inspector of Buildings DatT�
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.I 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(sy 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone'? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
1 caner'of Record:
Name(Print) / Address for Service:
.q
9 � CJ 7 L/ l-� — �S / L/
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bidg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-:
r� ✓1 e W a (LQI- fi nQ
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determine):
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier fix.
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S ��O ❑ Paid in Full ❑Outstanding Balance Due:
I
l
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.icense Number lispiruion Date
Nantc of CSI.- I(older I.isi CSL rrpe(see below)
'r Description
Address D Unrestricted(up to 35.000 Cu. Ft.)
R Restricted 1&2 Family Dwellin
Signature ki 1.1asonry Only
RC Residential Roofing Co%crin
-felephone WS Residemial Window and Siding
SF Residential Solid Fuel Burniny,Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or IIIC Registrant Name Registration Number
Address
Expiration Date
Signature rolcphone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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
1, 1-,- ` Q Q, , 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
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
1, 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.
Print Name - -
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to do hislher own work,or an owner who hires an unregistered contractor
(not registered in the liome 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 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.) Ilabilable 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 he substituted for"Total Project Cost"