8 CIRCLE HILL RD - BUILDING PERMIT APP (004) �, I'he C'onumm�sve:nhh of M;usachuscus
Boord ol'Building Regulations and Standards CI I'1' OF
Nlassachusctis State Building� Cute. M C'NIR SALEM kerise J.IGu--e)/l
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Ttru-fiurill. Dm eRlap
This Section For Official Uu Onl
Building Permit Number: Da iaJ;
Iluildinit 011icial(Print Mane) $gnat ow
SECTION I: SITE INFOR31ATION
1. ro rty AEress: 1.2 Assessurs \Isp dr Parcel Numbers
C"I rC I.la Is this an acstreet? es no Map Number Parcel Number
I.J Zoning Infon: I.4 Property Dimensions:Zmting Districtmposed Ilia Lot Area IN 11) Frontage(Ill
1.1 Building Setbacks(it)
Front Yard Side Yurds Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zane: Outside Flood Zone?
I4ibi(c O Private O — Check if ycsO Municipal O On gild disposal s)slcm O
SECTION2: PROPERTY OWNERSHIP'
It
r
Record: //
City.Stale.ZIP
e 223YZ9 1� K-cv- c \>�
Nu.unJ Street
relephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Existing Building❑ Owner-Occupied O 1 Repairs(s) O 1 Alteration(s) ❑ I Addition O
Demolition O Accessory Bldg., rofUnits I Other (3 Specily:
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Ilan Estimated Costs: OMclal Use Only
(Labor and ..\Laerials)
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
i '. EIcclrical S O Standard CityiTussn Application Fee
- ❑Tutnl Project Cost'i Item 6)x multiplier _._--x
). Plunihing S - 2. Other Fees: S_
J. \Icch.unical ,II\ \(') S List:
IFIre
Cu�+rcssiuot rotal .\11 Fccs: S_..-------
ck \'o. _Check Amounr. l'.uh \wounl:
I, I'Mal Project Cost: S 0 / ❑ Paid in Full D Outstanding Bal,unce Doc:
SECTIONS:
SEC I I OIN 151: ON IS,I-R I Cr ION SERVI(TS
"'
5.1 S
I ist 01. hisc lie,:1100it)
'11*01. Holder
)PC )cscriplion
No. ind.strvvt I[ I hircvicied I Buildillms ul)Ill 31222"1 It I
It lie,iricwd Itt 2 1:amil D%%ellill
iii %lawil
K Rixitin Opicrin
WS willdow.uld Sidill
SF Solid Fuel flumills Appliallves
Insulation
.-Finail address 1) Demolition
41.2 Registered Home lnil)ro%ement Contractor(1111C)
IIIC Rvil6traflon NumiZ I"Nilir,1110n Due
I IIC Compan) Mulle of IIIC Registrunt Name
No. mul Street Email address
CityCrown.State,ZIP reiephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 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 .......... El No...........0
SECTION 7s:OWNER AUTHORIZATION TO H FCOMPLETED 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.
Print Ox*ncr's Nuine(Electronic Signature) Data
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
contain in IN Ical n is pue and accurate to the best of my knowledge and understanding,I,
X
'L in In I! f Mte
14,11 omicri tit.sluiliortivilAgolt .4 Millie(1:14ctflillic SiVIIJIUM)
I. An Oiii,ncr\%hu obtains a building permit to do his.her u\vn \wrk,or an owner who hires an unregistered contractor
I tiot registered in the Home 1111provellicat Contractor 1HIC) Program),will no have access to the arbitration
program or guarant) lbod under M.G.L.c. 142.4. Other important information on the HIC Program can be round at
O% •" I Information on the Construction Supervisor License can be found at i;!-% .111,
2. \%lien substantial%sork is planneJ, provide the information below:
rota) hour area(sq. 11 ) (ilicluding garage. finished basement attics,decks or porch)
Groii It%ing Area I s4- it I Habitable foul',cellist
\timberoffireplaces Number of hedroklilli
Nlilliber t4hathrooms Number
I lie of licatilig st'Icill Nllmhcr
of decki• porches j
PV 01,cll
I of�oollltq 1:11clo'ed
I roi,il Protect Square Fool-we"MA be whllimacd I'of I"11.11 Proico('01C