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The Commonwealth of Massachusetts ICES
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR lift AUG _ E
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Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Familp Duelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signa �O
Dat2
SECTION 1:SITE INFORMATION
1.1 Property Ad ress• 1.2 Assessors Map&Parcel Numbers
MC 1 rrl 11
1.1 a Is this an accepted street?yes_ no Map Number Parcel Nu nbcr
13 Zoning Information: '1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(tt)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rest Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Fland Zone Information: 1.8 Sewage Disposal System:
Public 6fd Private❑ Zone: _ Outside Flood Zone? �//
Check if ycs0 Municipal pC�On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ZOwner'4ofcor
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Nam ] 1 � Ciry, —
22 4']
' 1 ���i �b3 petl�eoC� Ala, �J1n
No.and Street Telephone — Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildinggl Owner-Occupied' Repairs(s) Q Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Pmposkd Wo s
"R� nn�yis A fJ ( ) t e
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ a0O r 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/fown Application Fee
❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (AVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total A0 Fees:$
$
O Check No._Check Amount: Cash Amount
6.Total Project Cost: t () ❑Paid in Full ❑Outstanding Balance Due:
.�JC r'�T 7o H•O•�a Z(o
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings!!p to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
Cityaown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding,
SF Solid Fuel Rurnutg Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City,/Town,State,ZIP 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
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 Owner's Name(Electronic Signature) Date
SECTION 7h:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,(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.
Print Owner's or Authorized Agent's Name(Electron Signature) Date
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 can be found at
wwn;,.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.pov/dlis
2. When substantial work is planned,provide the information below:
Total floor 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 hearing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"