48 CHESTNUT ST - BUILDING PERMIT APP r
&SuildinSCommisse
he Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
assachwehs State Bwlding Code, 780 CMR, 1'"cdihon Budding Dept
rmit Apphcauon To Construct. Repair, Renovate Or Demolish a fOnr• tar Tivu•Funuls•Du'rfbngThis Section For ORcial Use Onl_ Date Applied:r �ua /Inspatar o!Buildings Dale
SECTION 1:SITE INFORMATION
1.1 Property Addreu: 1.2 Assessors Mop• Forest Numbers
X AS cHEs'rN yr sT
I.I a Is This an accepted street'? M�Number Parcel Number
yea no
1.3 Zoning lnformstles: 1.4 Property Dimensions:
Zoning District Proposed Use La Area list RI Frontage(it)
1.5 Building Setback$(it)
From Yard Side Yards Rear Yard
Required Provided Required I Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system 0
Public D Private O Cheek if s0
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
X A4N 1-1No I c6NNE�L Y
Pri ) Address for Service:
Signet a Telephone
SECTION 2:DESCRIPTION OF PROPOSED WORK'(check ad that apply)
New Construction 0 Foisting Building O IOwner-Occupied O Repairs(s) 0 1 Alteration(s) 0 Addition O
Demolition 0 Accessory Bldg.O Number of Unils_ Other O Specify:
Brief Description of Proposed Work
1,1 w cARIN T v I.
�l zt,�,InI:-- A R o U
/\ SECTION 4:ESTIMATED CONSTRUCTION COSTS
Wstimated Costs: OHlclal Use Only
Labor and Materials
g S I. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
cal S 0 Total Project Cost'(Item 6)s multiplierng S 2. Other Fees: Snical IHVAC) S Lisl:ical tFire S Total All Fees. SonCheck `o. _Check Ameunt: Cash Amount:
roject Cost S 3 O' f7(gyp 0 Pad in Full 0 Ouwandmg Balance Due
SECTION 3: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor IC
Licenw.Number Espu.nlon Dute
N•yae of('SL- Hptder
Li,t('SL Type Ire heluwl
AWirss T ,Description
U Unrestricted L4 to JS,000 Cu. Ft
5itnaiure R ResurciaPrilk.2 Family Dicellin
,%1 sla Onl
RC sidential R In covering
ickp W S 4Residenlial Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
fit Residential Demohirm
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Num Address
EaE ration Due
Signature Telephone
SECTION 6:WORMERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL/ 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 AO)davit Anachee Yes..........0 No...........0
SECTION 7m: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.
Si name of Owner Date
SECTION 71s:OWNER'OR AUTHORIZED AGENT DECLARATION
I. 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.
V aaHN H 00Ntg Et-Lr`
/\ Print N: u ^ /
Signature 0wner or Authorized Agent ' Date
(Signed un the aim and penalties ofperjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will qg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSLJ can be found in 780 CMR Regulations 110 R6 and 110 R3,respectively.
2. When subsranGal work is planned•provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area Habita
ble able room count
:Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Type of hearing system Number of decks porches
Typeof cooling system Enclo,ed Open
1 "Total Project Square Fooiage'•may he,uh,tituled for-'Total Project Co.t"