26 CHASE ST - BUILDING PERMIT APP ,10
(� The Commonwealth of Massachusetts
U C'J9
Board of Building Regulations and Standards F
Massachusetts State Building Code, 780 CMR, 7ihedition v
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numbcrf 0 Date Applied: IS < '-tom(/ a o
r
Signature: `��• r1iU ( y
Building Oommisslonertln� -t rof Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
e CC,& sf
L l 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 Il) Frontage(it)
1.5 Building Setbacks(R)
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: 1.9 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
p aL SECTION2: PROPERTY OWNERSHIP''
2.It0er'of�Record7 � C1n 1� � G�QA-f J_ )L
a�
Name(Print) Address for Service:
Gr"4— 0 I ;L
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s)jK I Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Workt:
r<
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials 011lclal Use Only
1. Building is I. Building Permit Fee:S Indicate how fee is determined:
I. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
. Plumbing s 2. Other Fees: S
4 J
1. Mechanical (HVAC) s List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
6. Total Project Cost:
Check No. Check Amount: Cash Amount:
S
8OOD ❑Paid in Full O Outstanding Balance Due:
�iA// lv0 54� 3v2
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) L-f 4 5({
AA 441,I D rL.P,tio-' License Number I:tplra Ian Date
Name of C'SL- of r �7� I.ist CSL Type(see below)
��{0 e �t'4-tS't-v �-� /kALf4vl ✓?'1A 1.. Description
Odd n `•
rs sa 4/D ( �/n�/p _ ) �� U Unrestricted u to 35,000 Cu.Ft.
oC. (/ R Restricted I&2 Family Dwelling
Sign//ar� (��t�ure II II M Muson Only
6A8 'T���*j RC Residential Roofing Covering
Telephone WS Residential Window and Sidinit
SF Residential Solid Fuel BumingAppliance Installation
D J Residential Demolition
S.2 Registered Home }mprove ent Contras�f r(HIC) I j R 13 A
!IIC Company Namee or m i1 a HIC Registrant Namee Registration Number
Address fi<ptrattan Dale
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 2SC(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 ..........0 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 matters
relative to work authorized by this building permit application.
Sianature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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.
SUS-( M d l a L2 D.Ut P-
Print Name
A/I r A
Signature of Owner or Authorized Agent Date
(Signed under the Rains and penalties of 'u
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 shave access to the arbitration
program or guaranty fund under M.G.L.c. I42A.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.RS,respectively.
? 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.) 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. "Total Project Square Footage"may be substituted for"Total Project Cost"