52 CHARTER ST - BUILDING PERMIT APP (002) ice- i i P�r V7
f The Commonwealth of Massachusetts
k ► Board of Building Regulations and Standards FOR
Massachusetts State Building Code. 780 CMR. 71"edition %WNICIII U.I"Il'
Building Permit Application To Construct. Repair. Renovate Or Demolish a Ret ocd Jutma,r
One- r Tit o-Farm)s Dn elling
Thi Section For Official Use Only
Building Permit Num Date Applied: _
Signature:
BwI ng CummissionI Spector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property :*,ddress: 1.2 Assessors Map & Parcel Numbers
�O Chkt 2n z ST.
I.la Is this an accepted street? yes no Map Nwnbrr Parcel Numb r
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ti) 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: 8. Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public IV- Private❑ Check if yeslil Municipal III'&site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
[7Nunv
1 Owner of Record:
tJ ,f'inU Address for Service:
7 F� 7 f-/Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ 1 Existing Building Owner-Occupied Ef Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
.*tf aep(GCE a yes
nstaCi NecJ ecK• t 4 7o r; aP C4-1 c
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ p 2sv 1. Building Permit Fee: $�� Indicate how tee is determined:
❑ Standard City/Town Application Fee
?. Electrical 5 ❑Total Project Cost' (Item 6) x multiplier x
3, Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire 5 Total All Fees: S
Su ression)
Check No.�Q�Check Amoum: Cash Amount: I
6. Total Project Cost: b I)ZPaid in Full ❑ Outstanding Balance Due:
I
I
SECTION 5: CONSTRUCTION SERVICES
Y
5.1 Licensed Construction Supervisor (CSL) ll�� �� af<�o�/ o
— ,p// /G, /A.1 r S�4� License Number E,%puaion Date rl
Nail I CSL- HulJle 6,10
`�// //� List CSL Type(see heluw)
7 f(<f3IG�� St- U/�UCQi ter. T Description
addr F � U CnrestncteJ nt m }4.IX)0 Co. Ft.
R Restncted IAA Fanul , Dsselhn
Signature onry Only
/-17Fl s-;Z-3 idential Routin Cocenn
`relephune %�'S Residrm ml \Vmdu s ,mJ Sidm
SF Residential Solid Fuel Bunune :\i i lance IINA Lwm
D Rnidential Demolition
5.2 Registered Home Improvement Contractor(HIC)
<!A Lf (!5' o 4- L -
HIC Company Name or HIC qge istrant Name Registration Number
�/ 4s Ico�v S / G/ �zatlz
c (97F1 K�3 —S']77 Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 9 2506))
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 .......... m— No ........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf. in all mailers
relative to work authorized by this building permit application.
Signature tit Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
f SA 4-to , 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
Signature of owner or Authorized Agent Date
(Signed under the 2ains and penalties of perjury)
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 M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations.110.116 and 110.R5. respectisely.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementlattics, decks or porch)
Gross living area ISq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms j
Number of bathrooms Number tit halt/baths
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,,