9 CHANDLER RD - BUILDING PERMIT APP The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
'i
�V I Massachusetts State Building Code,780 CMR SALEVI
Revised.Llnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Officia se Only
Building Permit Number: Date pplied:
Building Official(Print Name). Signature, - Date
SECTION 1:SITE INFORMATION
L I Property Address: 1.2 Assessors Map& Parcel Numbers
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 11) Frontage(It)
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,§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❑
SECTION2: PROPERTY OWNERSHIP,
2.11'�Owner[of Record:
N�nie(Print) City,State,ZIP
,:I r-W aim IQ�-
No.mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) d Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
BriefDescriptq(Proposed Work':
_,
SECTION 4: ESTIMIATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials) Official Use Only
1. Building S C)UU I. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
1 Plumbing $ 2. Other Fees: .$ h
4. Mechanical (I-IVAC) S List:
5. Nlechanical (Fire S
Suppression) Total All Fees:$
Check No. _Check Amount: Crash Amount_
6. Total Project Cost: S �J wv'� ❑ Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) (:��/ / LU/�6 l�
M qn�, License Nluombber Expiration Date
Name of CSL Ifoldeer
�( /, C \ t ` List CSL'rype(see below)
No. and Street (� T —N.e- Type Description
Unrestricted (Buildings Lip to 35,000 cu.11.)
/� ^^-�+ G L Z R Restricted 1&2 FamilyDwelling
City! o� ,Stat ,ZIP M Nlisonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
SPF'n_- � )o— I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) Z ()
Sf—n A.11d IBCHIC Registration Mumber Gxpirution Dnte
lilcc(mp;ul N��o IlIC Registtrrra Name
No.and Street TT Email address
L><n� CJI�i o L
Cit /Tov�v ,Statl, Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.,152.§ 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 APP ES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
\A )wna- ///z,f13
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below, I h by attest under the pains and penalties of perjury that all of the information
contained in thi • c'a s true and accurate to the best of my knowledge and understanding.
Print Owne ' or Authorized Agent's Name(Electronic Signature) Date
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 ibI.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
oww.mass. ov'oca Information on the Construction Supervisor License can be found at www.mass.,,ov!dM
�. When substantial work is planned,provide the information below:
Total floor area(sq. t1J (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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. -rota) Project Square Footage"may be substituted 1br"'rota) Project Cost"