22 CIRCLE HILL RD - BUILDING PERMIT APP (003) ti
r� The Commonwealth of Massachusetts ECEIVED
i Board of Building Regulations and Standards CHWECT OVAL SERVI
assachusetts State BuildingCode 780 CMR SALEM
N
Revised
Building Permit Application To Construct, Repair, Renovate Or Demolish a 31 A 4-
One-or Two-Family Dwelling
This SectionForOfficial Use Only
m Building Permit Number: 'Date"Applied
(`(Z Building Official(Print Name) �'. SignatureDate
I SECTION 1: SITE INFORI'V[ATION
1.1 lAro erty/�ddres ' l 11 Assessors Map& Parcel Numbers y
1.la Is this an accepted street?yes no tvlap 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 Zone? Municipal VOn site disposal system ❑
Check if yes❑
SECTION2:, PROPERTY'OWNERSHIP.' '
2.1 Ownert of R.cor l 5)1- /I/!,
Name(Pr� � 1 C I City,State,ZIP ✓ �� }/—� (�
No.and Street a e� mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building V1 Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of P os ork
I
Z
A'WI
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
ltem Official Use Only
Labor and Materials
1. Building S ,O)3 L Building Permit Fee: S Indicate how fee is determined:
�. Electricol $ �� ❑ Standard.City/'Town Application Fee
❑'Total Project Cost' (Item.6)x multiplier x
3. Plumbing S ^ 2. Othe[Fees: S
1. Mechanical QiVAQ S ^ List:
5. Mechanical (Fire $
Sn ression) Total ,111 Fees'$
Check No. _Check Amount:_ Cash lmottli r ,
r 1'11tal Project Cost: S 1 ❑ Paid in FnII ❑Outstandin 11 dance Duo
M1kt t. ro M1� D " rnr \�� 5( b
SECTION 5: cONsTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Gspirrtion Date
Name of CSL Holder
List CSL Type(sat below)
No. and Street Type Description
U Unrestricted (Buildings up to 35,000 cu. R.
__ R Restricted 1&2 FamilyDwelling
City/Town, State,ZIP DI Nlasonr
RC Roofing Covering
WS Window and Siding
SF Sulid Fuel Burning Appliances
[ Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
IIIC Registration Number Expiration Date
I IIC Company Name or IIIC 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 7b: OWNEW 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 it thi application is true and accurate to the best of my knowledge and understanding.
Print Owner' or Autborized Ay It's Name(Electronic Signature) �— Date
NOTES:
I. :kn 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 ttot have access to the arbitration
program or guaranty fund under D.G.L. c. 112A. Other important information on the IIIC Program can be found at
www.masxeovhxa Information on the Construction Supervisor License can be found at uyw—v s.-to�(ILL,
[2. W'hen substantial work is planned, provide the information below:o[al floorarea(sq. Q.) (including garage, finished basement/attics,decks or porch)
ross living arca(sq. 11.) 1labitable room countumberof tirep1accs.__ Number of bedroomsumber of bathrooms Number of halbbathspe of hc.rtin1,system Number ofdecksi parches
peofcoolingsystem Enclosed pen
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