37 CHESTNUT ST - BUILDING INSPECTION (5) CAR � �
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The Commonwealth of Massachusetts INSPECTION L SEIfiFD
i Board of Building Regulations and Standards
ij Massachusetts State Building Code, 730 CMR 6a�,It 2011
slip SEP 2 Rre?se
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date; plied
Building Official(Print Name) ignature Date
SECTION L•SITE INFORtV[ATION
1.1��rty�,d, ess• �"/ y 1.2 Assessors Map&Parcel Numbers
1.1a 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water pply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public Private[3 — Check if es❑ Municipal Cl On site disposal system ❑
SECTION Z:; PROPERT1f OWNERSHIPL
2.1 Owners of Re c d•
Name(Print) t ,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK check 1 that apply)
New Construction❑ Existing Building❑ Owner-Occupied 0 Repairs(s) Alteration(s) 13 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed!
S1
SECTION 4: ESTIbLATED CONSTRUCTION COSTS-
Estimated Costs:
Item OfQdal Use Only
Labor and Materials
1. Building $ �jO, I..Building Permit Fee:S' ` ' Indicdtehow fee is determined:
�. F.Iccnicat S ❑Standard,Cityfrown•ApplicationFee
❑Total Project Cost(Item.6)x multiplier x
3. Plumbing S 2. Other Fees:'S
1. Mechanical (IIVAQ S List:
. Mcchaniail (Fire $ _
5n , ressian) — - Total All Fees:.S_
Check No. Check Amount: __(.ash luwunt•.
('ntal Pro Cost: S JOO., p 1'lid in Full 0 Outs ndim; Balance Into:
srcrlON 5: CO;NS'i-RUCTION SERVICES
5.1 Construction Supervis6'r License(CSL) 022-j4—
CS.Q 02�f2r�6t,l I R t LicenseNlunber C pirat' ❑Date
Name ot'CSL Ilolder
List CSI.'fype(sea below)
No r t TYPa - Description
U Unrestricted(Buildings up to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
City town, State,ZIP bl %lasonr
RC Rootin Covering,
1VS Window and Sidin,
SF Solid Fuel Burning Appliances
Insulation
I'cle Iona Email address U Damolition
5.2 Registered Ho to Im roveme t Centrac�tor(HIC)
�,-. . FI[C Registration Number E. pira on Date
11(C t'ottnpany me or IIIC Re s rant e
No.aneet ^ _ ]� . � Email address
City/Town,State ZIP rele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 1,52.§ 2SC(6))
Workers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes ..........Gr No...........❑
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.
Print Owner's Name(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.
9
Print is or Autlturie�4;ent's Name(Electronic Signatt � Date
NOTES:
1. ;1n 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 H(C Program can be found at
www.m;us.eov/oca Information on the Construction Supervisor License can be found at arww.mns . uy�rJL
2. When substantial work is planned,provide the information below:
rord tloor area(ml. tt.) —(including garage, linished hasementlattics,decks or porch)
Oro;i living area(ml. It) ._ Habitable roout count —
Miniber of tirepl,las_---------- Number of bedrooms _
Number of bathrootmi Number of half-baths -------_— -----
fppe of healing iyileut
------ ---- -------
1'%peofcoolingiyitcna _._.--- -_---. Enclosed — Open --_--
t. kit 11 I'rU l.'l( squ 11'd Foot.)-'e Ill.ly be illbitlllll"d t,lf I'I'lllecl Co't"