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1 CIRCLE HILL RD - BUILDING PERMIT APP The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State'Bi lding Code,780 CMR, 7h edition MUNICIPALITY. USE. Building Permit Application To Construct,Repair,Renovate Or Demolish a RevisedJanuary. " One-or Bvo-Family Dwelling I, 2008 This-Section For O al Use Only' Building Permit Number: Aplied- Signature: f''h Building Commissioner!Inspector of 'dmgs ate SECTION 1:SITE ORMATION IJ Prc)nw y ddress .: ". n 1.1 Assessors Map&Parcel Numbers 1.1 a Is this as accepted street?yes_ no_ Map Number - Parcel Number. 1.3 ZoningInformation: - 1.4 Property Dimensions:. Zoning District Proposed Use. Lot Area(sq ft) .' Frontage(R) , I.S.Building Setbacks (ft). -Front Yard Side Yards Rear Y.ard ' Required. Provided Requimd - Provided Required Provided L6 Water Supply: (M_G.L e 40,§54) 1.7 Flood Zone;Information:... 1.8 Sewage Disposal.Sysfem- Zonc Mond ood Zone?.. Public❑' ' Private❑ — Check ifyes❑ Municipal.0 On site disposal system ❑ ' _ SECTION 2-. .PROPERTY OWNERSHIP'. 2.1 Own ggr'of Recod: G�U\SSu� Name(Print) _ Address for Service - 3L4 Signature Telephone. - SECTION 3:.DFSCRIPTION OF PROPOSED WORK2`(cheak all that apply)" . ;•,ev'CcanRncC Gn ❑ "E is^rg B tildLig.lY Or:ier--^^cup:^ ❑ bePai s(s)" ?.1•eratica(s) CT A:Idrtioc t] Detn6litinn ❑ "AccessnryBlde. ❑ 1 1JumberofUnits_ Other-C .Spmiry:_ .: :y Brief Description of proposed Work': c W vv-AV a SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials Official Use Only I.Building $ L t+ aa� 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Fown Application Fee P Total Project Cost'(Item 6)x multiplier —XL 3.Plumbing $ 2. Other Fees: 4.Mechanical (HVAC) $ List 5.Mechanical. (Fire Su res ion) $ Total All Fees:$ ti aa� to CheckNo. Check Amount. Cash Amount 6,Total Proi ect Cost: $ ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTI N-Spey ES 5.1 Licensed Construction Supervisor(CSL) - L(L^ kA_ksd . . License.Number .Expiration Date. Name 1fC 1Sl lder \ tO16d3 - ListCSLType(seebelow) - _ upi tion Address - T.':e 9 :S:-i1 :'a U Unrestrie'ted to 35,000 Cu.Ft.) Signature '�� . . .. R Restricted l&2 Family Dwelling Masonry Onl . - RC Residential RooSn Coveri Telephone. �(_SS-t�8� _ WS Residential Wmdowand SM P— SF Residential Solid Fuel Buming Appliance Installation - - D .Residential Demolition • - , 5 2 Registered' ome Irqprovelcient Contractor(HSC) nit,Co y Name or ]C Re ' nt N e Registration Number - - t 1 � s01i ra i/1 Z51S�a Address -. ...... .. t a. 1L jti$ 3S\ �aUo Expiration Date Signature. " Telephone )(SS SECTION 6:WORKERS' COMPENSA i-tON lNSURANCE AFFM 4VIT(M.G_L.c.152_§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide . this af5davit will result in the denial of the Issuance of the butlding permit Signed Affidavit Attached? ' Yes : ........0� No. SECTi01`�i 7aa:0'�R�a-I1THb$i'�:43ZPN TO BE•Cp11hP�ETFrD yJ�N'.. ' . OVaMR'S AGENT, m7,-C'QAYRA C.OR APPLIES ROR$I7II 3i F�S�t71'�T - as Owner of the subject property hereby authorize_ Y�.r h nt ld� to act on my behalf;in all matters relative to work authorized by this building permit application. . - - Signature of Owner . - .. - - Date - . -SEC/�3?ZlaAi`7brO�TER'�ORAiJ'1�mRI�ED:?;A?ta�dA���',�7�,A�:eq�©N: .: : -- I_ y+. ^,ham` >1 ✓t GJt�., _ 1W,neh nY'A4thoiizgd Agent iterel+y Qe41a#C...= . -- dfat the;tatca+tnts acid iufomranonfere�oin"'tr lica6on'aret rte aisd accuralr to the hes o - FF I f 'm, 1»owkdscand .behalf. . Q � a` ' ':' : : ,:_ ..., -.. .. � ' tT(�10.n' V(V\6 Ci i-1 _ .Print Name, - v Signature of Owner or Au orized Agent : Date :. (Signed under the pains and ptiialties of pltdu - NOTES: 1. An Owner who obtains a building-permit to do his/her own work,of an owner who hires an unregistered contractor (not registered in.the Home Improvement Contractor(MC)Program),will not liavo access to the.arbitration program or guaranty fund under hLG L c. 142A..Other• ortant information on the H1C �P and Construction Supervisor Licensing(CSL)can be found in 7g0`CMR Regulations l I0.R6 ander 11D0,RS,respectively. 2. 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 ofbedrooms Number of bathrooms N ember ofhalf/baths Type of heating system Number of decks/porches ' Type of cooling system Enclosed Open 3. "Total Project Square Footage'maybe substituted Tor"Total Project Cost" q DDI L du