7-9 CHERRY ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
SA
Massachusetts State Building Code,780 CMR Mor
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section F drOfficial Use Only
Building Permit Number: Date Appli d:
Building Official(Print Name) Si ,ture Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
2-'7 C H6k2v t�
].la Is thistreet?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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❑
SECTION 2: PROPERTY OWNERSHIP'
2A Owner'of Record:
i /UHZi4i�e 1� 67�_� a � g6o
Name(P`nt) Ci ,State,ZIP
�y 6VK1 L
No.and Street lephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑TEMng Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition[-0
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work :. -
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ! I (� (� ❑Paid in Full - ❑Outstanding Balance Due:
*oi
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) / / r _ J/
�An/ ���y���C icense Number Expiration DateDate
Name of CSL Holder
List CSL Type(see below)
y c L � 5 Type Description
No.and Street
U Unrestricted(Buildings up to 35,000 cu.ft.)
YN �✓ �hQ a '7 D S R Restricted 1&2 FamilyDwelling
City own,S tate,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�� > SF Solid Fuel Burning Appliances
' yq� / ®Z/9/I�I� ., I Insulation
Tele hone Email address D Demolition
5.2 cRegistered Home Improvement Contractor(HIC)
Vgri lYJ�qi S HIC Registration Number Expiration Date
HIC ompany Name or
'H IC R7istrant N
' ; sam e
C //67yor.r
No dCset Em� Rb
alcl
Ci own,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...........❑
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
�(1��/ NAZAi RE acl— Za
Print Owner's ame(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
�2�1-AgF� s ocT3 ZB
Print Owner's or Authorized ent's Name(Electronic Signature) Date
NOTES:
1. 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 can be found at
www.mass.cov/oca Information on.the Construction Supervisor License can be found at www.mass.�ov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost'