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7 CIRCLE HILL RD - BUILDING PERMIT APP r / I Fhe C•onunonwealth o(Messachuscits Board of Building Regulations and Standards CI I'1'OF s Massachusetts State Building Code, 780 C•MR SA L E,%I Building Permit Application To Construct, Repair, Renovate Or Dent a One- or Tnv-Famils Divellint� This Section For 011icial Use Only Building permit Number: Date pplied: 3 /oZ lNilding 011icial(Print Name) .'ignalurc Uule SECTION I:SITE INFORIIIATION 1.1 Property,A fe s 1.2 Assessors %tap& Parcel Numbers 1.la Is this an accepted street? ''es no Map Number Parcel Number 1.3 Zoning Informs Ion: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area IN It) Frontage III) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required provided 1.6 Water Supply:(M.O.I.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public O Private O Zone: — Outside Flood"Lune?Check if esO Municipal O On site disposal s)stein O SECTION 2: PROPERTY OWN ERSHIPI 2.1 Ow erI of Record: �114i rJ�1 n Jrl i h�// 5 �ePn n/3ss _ e%y 7 Nanc(Print) City,Stoic.ZIP4 2r/r �I. J IUD _ `7 `3/ 7/`5 ( v?3 - No.and Street Telephone Email Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ f Alteration(s) 01 Addition ❑ Demolition O Accessory Bldg. O Number of Units_ I Other Specify: Brief Descriptio oPrpIodWork P — 72 Z 5i' rw f rip I SECTION J: ESTIMATED CONSTRUCTION COSTS lien Estimated Costs: Official Use Onl ILabor and \lalerials) y 1. Building S 7 fj� , I. Building permit Fee: S Indicate how fee is determined: '. Electrical S � ❑Standard CityrTuwn Application Fee ❑Total Project Cost'(Item 6)x multiplier —.___x l J. I'lunhing S /, 1, Other Fees; S — J. Mechanical III\'.\('1 S List:- -_-- ' S. \Icdt:mic;d iFirc --..--- -- --- . . . . tiu+vc>sionl S Total .\II Fees: S_ ('heck Nu. ('heck :lntrnnu: l'_ .uh \mount: n. Tulal Project Cost: S O �p CO paid in Full ❑ Outstanding BaLuice Due: �g u 1 , SECTION 5: CONSTRUCTION SERVICES � 5.1 ('onstructiou Supervisor Liccnse(('St•) I icense Numhcr FNpuotion Uatc Nalnc of('SI. I)older - I iet CSI. f)pc(sec CaU _________—__ -- .I.)Pe Dcs;•riplion No. and Slrecl y{� ll =,d J I ILIiIJin�s li n, 15,11110 cu. IL1 � r R IR2 Fall D»cllinC'IN ifoan.Slate.Ll P ::�A occrin nd Sidin Burning Appliances l'cic hone h:mail addresscmolitian5.2 Rr isteredHome Im srw'e 1 lit,Contractor,(HIC) �f�� 6 C/ (� � (J/r/�©-,-w C,, IIIC Regiitrni n My r I:SpIr;IllUll Date I IIC Cuutpa ) one or I IIC'It, gis r•at NOIIU: / - 5 Nu.and,�n��e}, �c,� 3 j Email address /�f V- 7Uy 7^70 Ci /Town,State,ZIP rele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 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 .......... O No...........O 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. Print O,mcr's Nume(Electronic Signature) Date SECTION 7b:OWNERI 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. I'ri»t Ossncr's nrAtutiorirvd Agwt's Namc I hlectrunic.Sign:nurc) Duto NOTES: 7he-nsubstantlal r whu obtains a building permit to do his her own work,or an owner who hires an unregistered contractor tered in the Home Improvement Contractor I H ICI Program).will nu have access to the arbitrntiun or guar am) fund under M.G.L. c. 11_'A. Other important information on the HIC Program can be fount at tru•tion Supervisor License can be found at +,„+N nl•n; � % -It's .. ��, , ,.I Information on the Cons v p2. stantial work is planned, provide the infunnation below: a Isy. ft.) _ _____._I including garage. finished bascmentattics,decks or parch) cross livingareaI sq. 11.) _ flabitable room count \unlheroffireplaces .._ -..... _ ... . Numherotbcdrooms _. Number ot'hathrooms . . _ _ . . \umber of half haths I\pe of heating s)Nlenl _ _ \u»Ihcr of decks, porches r)pC o1 cool jilt. i�itel❑ I'nclaseJ .. Open i 1, "IoI'll Project Square Ioolagc- lua% he substituted li,r"I'otal Project Cast'