8 CIRCLE HILL RD - BUILDING PERMIT APP (003) / I lue C'onunomvcallh of Massachuscus
y; ;a Board of Building Regulations and Standards CI IN OF
Massachusetts State Building Code. 7SO C'NIR 5,\LIiMI
(L„ Revi.wd thu'JI)l/
Building Permit Application 'ro construct. Repair. Renovate Or Demolish a
Me-or 7'ur)-kan tv Duelling
This Section For Official Use Only
Building Permit Number: Date,\pplicd:
Building 011icial(Print Mune) Signature Dole
SECTION I: SITE INFORMATION
L I Property Address: 1.2 Assessurs \lap& P rcel Number
1.la Is This an acre ted street? es no Map Nwnhcr Parcel Numhcr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lill Area(sq 11) Frontage(11)
1.5 Building Setbacks(fl)
Front Yard Side Yards Rear Yard
Required I'ruvided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
MIME❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal On site disposal s)atom ❑
SECTION3: PROPERTY OWNERSHIP'
I.I Owner'of Record: M 7
N;une(Prim) City.State,ZIP
746 1 —
Nu.and Street Telephone Fmuil Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Iteration(s) ❑ 1 Addition ❑
Demolition ❑ I Accessory Bldg.❑ 1 Number of Units_ Other Specify:
Brief Description of Proposed \Vork':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Ilan Estimated Costs: OMNI Use Onl
t Labor and.Materials) y
I. Building S 1 I. Building Permit Fee: S Indicate how fee is determined:
'. Flcarical 5 ❑Standard CityiTusvn Application Fee
❑Total Project C'osO I item 6).x multiplier
1. Plumbing S ,. Other Fees. S_
a, Med:hanical ill\.1('I 5 List:.—
' �. \Icdtanird 1 Pirc -
I
I, Total I'ruject Cost: 5 S~7 ('hccA No. _ _('heck:\mount - -.---- (',uh \m unC
O Paid in Full ❑Outstanding Bdauscc Due:
��� e5::� ie—� A
SE('I'IONS: CONS I'RICTIONSERVICTS
i.l ('unstructimr Supen'isur Liccnsr(C'Sl.l - �� j r/a r !% 7 2-6
- �—
. Cy6dt- 1 icen.c Nunlhcr I Ir,ul a U;nc
N;nuc ol'l'SL I InIJe
I is(.St. I'%pc(sec helua).__.__.._
' Ntl. ,utd.l tract
> a ` .W l l Inreslri.IcJ l'fuilJin s a Io 15,I111U cu. 11.1
_ _ !/ 6 R I(a.,lri.ted I l_f.unil D„cllin
fits ' ,ie n,.Vale.LlP� �—._—. SI Alasun
RC Itti,11111A C'ovcnn
SF SoliJ Fuel lhuningAppliances
97U "� I Insulation
Ttic liana Finail address U Demolition
5.2 Registered Ifume Improvement Contractor(HIC)
LQ A./, � s'(J•�L.�S' �d�r/ - IIIC Rcgisualiun Mlmher '.cpin-wn Ualc
I IIC'C�tpan �alpv ur I c,01tegjaltant Name /
N wIJ 'ucel S. Qe®Cd/ Email address
tityfTown. State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2. 1 2!C(6))
Workers Compensation Insurance affidavit must be con ted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7s: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,vrler's Nmne(Elccuunic 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.
-;c (Sn? �2 4 . e� a�� 3 z7 a_
cr/2
I'rinl 0„ncr's or A ighoriMAgoll's Nmnc olcclruni Signature) ulc
No TES:
70\%nerer who obtainsa building permit to do his,her own work,oran owner who hires an unregistered cuntractur
stered in the Hume Improvement Contractor(HICI Program).will nu have access to the arbitration
ur guaranty fund underNI.G.L.c. IJ?A. Other important information on the HIC Prugrmn can be l'ound at
.. of �v.l Information on the Construction Supervisor License can be found atbstantial Durk is planned,provide the information below:
ea(sy. ft.) _ ____,._(including garagt, linished basement attics. Jocks or panto
Gross lis ing area 1 sy. It --_. _ habitable roues count _ .. .... . ._
i Nunlhen,l'tircplaces NunlhendheJnxnns .. .. .. . .
I \umher kit bathrooms .. .._ Nunlberufh;lifh:ulu
I pcot'heating >ystem _ Nuntherofdccks, parches
I 1 pe al eJVl111g i\ile10
Open
1, "I',aal Proj"t StIUMC 1'1101d4e" I11a1 he auhititwvd I'or •I'owl Project Cost"