14 CHANDLER RD - BUILDING PERMIT APP .1
The Commonwealth of Massachusetts MSP
Board of Building Regulations and Standards :DemolqD15
i
9 � Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or
One-or Two-Family Dwelling
r This Section For Official Use Only
Building Permit Number: Date A plied:
(� U, 1 io lvll�r
Signature,
. . Date
i -Building Otticial(Print Name). gn
SECTION L•SITE INFORb1AT10N.'
I_ I. ro�perty, s� 1. assessors t�iap&Parcel Numbers
1.1 a ids t/his GN an accepted street?yes no Map Number Parcel Number
1`34oning Information: 1. Property Dimensions:
Zoning District Proposed Use Lot Area(sy R) Frontage(Il)
1.5 Building Setbacks(it)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
I.6 Water Supply:(hI.G.L c.40,9 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes13
SECTION2: PROPERTY OWNERSHIP,'
2.1 �nner:lf Recor c . O_ IVA 01 70
N / - Gi'..C�c.v�—
m City,State,ZIP
l�/ (%lCt v c//n✓ �G/ 78/- 9S6 -41307
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
-� Brief Descri Lion i'Proposed\York=: Q
G f4 V, b Z CALL 1. Cb G
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) -
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing $ V Qther Fees: .S
4.�%ILchanical (HVAC) $ List:
5.Mechanical (Fire $ 'rotal All Fees:$
Su ression)
Check No._Check Amount: Cash Amount:
6. Total Project Cost: Q!>0 0 Paid in Full 0 Outstanding Balance Due:
,t
SECTION 5: CONSTRUCTION SERVICES
5.1 Coiistructimt Supervisor License(CSL)
License Number Expiration Dale
-
Name of CSL Holder List CSL'rype(see below)
Description
No. and Street Type' -
U Unrestricted Duildin s tip-to 35,000 cu. It.
R Restricted 1&2 F:rmil Dwellin
City/Town,State,ZIP M Masonry
RC Roolina Covering
WS Window and Siding
SF Solid Fuel Burning Appliances .
I I Insulation
Telephone Email address f D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street - Email address
Cit iTown State ZIP 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...........l7
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED.WHEN) "
OWNER'S AGENT OR CONTRACTOR APPLIES 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.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By c ring my name below, I hereby attest uncKr t ains and penalties of perjury that all of the information
con in d in this applic ' n is true Cacc rat tot best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Eta Signauve) Da
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 nor have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
w+vw.mass. god yjSO r Information on the Construction Supervisor License can be found at+vw+v.mass.,ov;Jns _
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) +n ,(including garage, finished basementlattics,decks or porch)
Gross living area(sq. ft.) - Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of h;df76aths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Toml Project Square Footage"may be substituted for•"fatal Project Cost'