20 CHANDLER RD - BUILDING PERMIT APP (002) (� /\ ,� The Commonwealth d(,Nlassachusetts , CITY OF
Board of Building Regulations and Standards SALEN[
Massachusetts State Building Code,730 CN[R Revised Mar 2011
Building-Permit Application To Construct,Repair,Renovate Or Demolish a
One-or,71i+o f a Iy PDw Iung
TkisSecuonFor�fficialU O ly ':
Building Permit Number-. Date A idd?.
tOKj`I GI
Building Official(Print Nnrae) .• :`Si Data:
SECTION L SITE INFbRNIATION
1.1 Pro erty AddreLss: s A, 1 Z Assessors Map�c Parcel Numbers
I.l a Is this an accepted street?•yes no_ Map Number Parcel Number
1.3 Zoning Information:' l.4..Propertybimensions.
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) .
1.5 Buildiag:Sefbaeks;(tt)
Front Yard- SidcMards Rear Yard
Required Provided,.. Required Provided Required. Provided '
'66 Water Supply:(M.G.I,a,40,§54) 17 Flood Zoae Information 1.8 Sewage Disposal System:
Zone Outside Flood Zone?
Public if Private❑' ' 'Municipal wo site disposal system ❑
t ieck{if esO _
,. . . `5Y•±CTION 2,'PROPFRTlI OWNERSIIII't' ' ::. . .: .
2.1 Owners of Record: � _ 1-5 � � Ll
Name(Print) City,State;ZIP
ao omN D11 �? I 70
No.and Street Tel'ephooa. Email Address
SECTION 3: DESCRIPTION`OF PROPOSED WOR10 6beck all that apply)
New Construction❑ 1 Existing Building❑ .Owner-occupied Repairs(s) ❑ Aiteration(s) Addition ❑
Derdol~hon /:❑- -Accessoq,Bldg;;O Number of Units_ `Other p Specify
Brief I)escriptis--on�ofPropased W�rlc� ��/ /iloJi�`E.- / � - "/2c�am U �iLug :•-o-u
SECTION4: ESTIMATED'EONSTRIJCTION,COSTS',
Estimated Costs:
Item Labor and Materials) Official Use Only-
t. Building S. 1 Building PermitF' S Indicate how fee is determined:.
2J
2. Electrical S ty astandard CityfrowrtAppiicshonFee
❑ rotal Protect Costs(Item.6)xinultiplfer. x
3. Plumbing S .7 5�0 GU 1', Other Fees. S' i
1. Mechanical (HVAC) S List
5. Mechanical (Fire
Cotal:CII Fens 3
J'n r ression $ L
Check No. Check Amount: Cash Amount-.
6. '1'nt:d Project Cost. S �/j 3-10
i-O. ( 0 Paul in Fill . 3 Outstanding B ilanwI Due..___._._
oo
SECTION 5-CONSTRUG r10N SERVICES
5.1 Construction Supervisor License(CSL) ,
kS r9U GAT (2 License Number Expiration Date
Name ot'CSL Fielder
/ List OL Type,(see-below)
7
l)escnpnon „
No.;Snd Street {.._ y ,
/ U=' Unrestricted Buildm u to 30 000 cu: tt
Cityfrown,State,ZIP .N[aso s
RC. Roofin .Covein`
%<WS ' :Window,uinSidin
�, 5F Sohd;Fuol Bu_rningAppliances .�.,,,,,n
Z "-F[n's41i tion
ftle hone "Emad.Stddress` £ - 'D Demolition 1
> . /
5.2 Registered Home Impravem'ent Con trac tor(H[C)
HICRegistrationNumber EioiAt-ionDate ,
ItiC umpany Name or HIC Registrant Name--,
7 raP/ W EC
No.and Street '
5;5 E Email address "
G /Town,State ZIP Tete hone
SECTION 6 WORKERS',COiYIPENSAT{ON INSURALYCE A FFIDAYIT(M G.X.e. 152.§-2sg6))
Workers Compensation Insurance affidavit must be completed"and submitted with this application. Failure o provide
this affidavit willresult in the dental oEthe Issuance of the building permit
Signed AffidavitAttabhedT Yes :. ❑ , ,;, No IB' .'
-
SECTION 7a OWNER AUTHORITiATION T0'BE COMPLETED-WHEN '-
OWNER'§AGENT,ORCONTReLCIUR:APPCIFS.FORBUILDL�IGPERMfr
�( 1,as Owner of the subject property,hereby auth itiie' -
to ac on my behalf mail to lative,to wo authorrzed by this budding permtc apphcatton 1
+GAG
Print OsName(Eteptt `preStgnatu
z,
'i s �' k
By entering my name below, I hereby attest under"the patgs and penalties of perjury that all of the information
contained in t is true a accurate to the best of my knowledge and understanding
L t T
trim t7 rice's or Atiihonecd.Agent s Name,(Electronic Signature)- �x' • D�tt
( I. An Owner who obtains a;bwldmg permit to do his/her owr work;lor an owner who hires art unregistered contractor:
(not regrstered m the Horne hnprovzment Contcacwi(H[C)'Program),vdl ii�r hove acctss to'the arbitration x
, a
program or gu'ardnty funtt under 6[G L c Ids Othentmpotl.tmt tnforrnahon on the FI[C Program can be found at h
,oww nt ta..ao'woca htformahon on the Cotts"�i' etto S peNtsbr[ tense can be found'a[ce�ccr m_ �c� os -'�'-
� ,
�. When substantial work is hdne; rovrde the tnformatmri below: :
P dp
Totahtloorarea(sg R) (including gamge'`fintshed basement/lntcs,decks or porch)
Gros livutg trey(sq ft.) Habitable room count
Noun erot'tirepladta Numberofbcdrogns
�uinbtrofbathrooins NumbeeufhtlWaths
Cypc of h umg systun Numhetut I ks/porches "
�y pe of wohng iyat�m _ FIlk:0 e l _ tlptn ",.
i "Ibt d Project Syu tr. oot t may"bc,ub,tihmd t,r I
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