34 CIRCLE HILL RD - BUILDING PERMIT APP The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
;k Massachusetts State Building Code, 780 CMR, 7" edition Building D •t
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Duelling
This Section For Official Use Only
Building Permit umber: Date Applied:
Signature: ' Z. -
` B ding Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
Ll roperty Add sus: /�I Ir ed 1.2 Assessors Map& Parcel Numbers
I.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 R) Frontage(R)
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:
Zone: _ Outside Flood Zone?
Publieb� Private❑ Check if yes❑ I Municipal)'3,On site disposal system ❑
2.1 Owner of Record:
SECTION 2: PROPERTY OWNERSHIP'
y G . //
� TI lSn� fd r+� 3 / trG
Name(Print) Address for
1-7(11Ice: -5 3 5 y /
Signature Telephone b
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Rcpairs(s)�W Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': /
R,QM o�/G I I✓n t c D� C✓• `a ri r+0✓- /a o��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 3, 6200 I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ S v(] ❑Total Project Cost'(Item 6)x multiplier x
E4Mechanical
umbing $ 0 (� 2. Other Fees: S
(HVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 1000
0 O 0 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 1; 6 q 9.)
+AJrl /I vvv^QrS License Number Expiration Date
NBmc of CSL-Helder List rQ l j List CSL Type(see below) G S
Type Descri tion
A U Unrestricted u to3S,uuuku. Ft.)
R Restricted 1&2 Familywe in
Signature �Oa� C M Mason Only
°� 0 / J RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning AEpliance Installation
D Residential Demolition
5.2{Registered Home tmprovemgnt Contractor(HIC)
1 � 6y95
4 �d� f�, : rO^ - Registration Number
HIC Comp an Name or HIC Registrant Name
Address yh (� 9O yD y 5 Expiration Date
Sig r Telephone
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 .......;�1 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.
Signature of Owner Date
SECTION 7b: O WNER' OR AUTHORIZED AGENT DECLARATION
i1
1 hd t 1—r /
G-e✓ 5d l i ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. fj✓ S /
Print Name
Signature of Owner or Authonzed Agent Date
(Signed under the pains and penalties of r'u
NOTES:
I. 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 110.116 and 110.115,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"