7 CIRCLE HILL RD - BUILDING PERMIT APP (003) The Commonwealth of Massachusetts
� OF
Board of Building Regulations and Standards CITY M
Vi1 Massachusetts State Building Code, 780 CMR SdMor
Revised Mar 2017
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 Applie
6. 3
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Pro,iierty Addre s: 1.2 Assessors Map&Parcel Numbers
C dI go
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 Supply: (M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood lone? Municipal ❑ On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: -
F>to 1i.i K n-flee I e w. MA 0 ig70
Name -
-7 cirCu �78- g-1g-Sa�fS
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) UPIAddition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ L to-oa r 1. Building Permit Fee: $ Indicate how feeds determined:
2.Electrical g ❑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
Suppression) Total All Fees: _
1 Check No. _Check Amount: Cash Amount_—_
6.Total Project Cost: $ I I[QQfj 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5..}1 Licensed Construction el
(CSL) 3_3 5 �
p I'u=-ir r-Z t/ License Number Expiration Date
Name of CSL-Ho der
�(
- List CSL Type(see below)
I fir?
AfP es Tye Description
Ft
J � U Unrestricted u to 35,000 Cu.FC)
R Restricted 1&2 Family Dwelling
Si n�alture M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvegment Contractor(HIC)
HIC Compapy Name or HIC Registrant Name Registration Number
S (Vei tt � 51 ' ` aleG` I9 6 ddres q ^7 i/ �f
12 I LLL- 1 i Expiration Date
Signa re 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
as Owner of the subject property hereby
authorize ' r- c'{-'n 01A.-e ✓' -7,6 rZy to act on my behalf,in all matters
relative to work authorized by this building permit appltcation.
C0V1 raC - S= a a, 3
Signature of Owner Date
SECTION 7b: O^W�NER' OR AUTHORIZED AGENT DECLARATION
I, l �rl S+vp �r ,as Owner or Authorized Agent hereby declare
that the statements and in onnation on the foreg mg application are tie and accurate,to the best of my knowledge and
behalf.
S lam✓
Print a
S
Signature of Owner or AVthorized Agent Date
(Signed under the pains hd penalties of er u
- - - ` = . - - - - - -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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I l O.R5,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 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"may be substituted for"Total Project Cost"