6 CLARK ST - BUILDING PERMIT APPS � The Cummonwcalth of Massachusctts Town af
^ I+ Board o(Building Regulations and Slandards
{�—� ,��� Nassachusrus State Building Code, 780 CMR, 7'"cdiuon BudJi�
� ( Building Permi� Application To Cunstruct, Rrpair. Renovaie Or Demolish a �
\, One- ur T�co-Fumilt�Du�r!ling
`� This Section For ORcial Ux Onl
��
� �� Da�e Applied:
Bwlding Pertnil Number'
ao •t� • o �
� Signatur
Bwl � Commisvoner/Inspec�ato(8wldings �+��
� SECTION t:SITE INFORMATION
I.1 Property Addres�: 1.2 A�sesaon Map d� P�rcel Numbers
� ` � s M� Number Parcel Number
� I.I a Is ihis an accepted streeY� es �o P
I.J ZoninQ Inform�tlon: i.1 Property Dimenslom:�
Zoning Dis�nc� Proposed Use Lo�Arca(sq R) Fromage(R)
1.5 BufldlnQ Setb�ck�(R)
Front Yard Side Yards Rear Yard
Required Provided Requircd Provided Required Provided
1.6 W�ter Supply:IM.G.L c.40,SSa) 1.7 Flood Zone loform�tion: 1.8 SewaQe Dlspo�d Sy�tem:
Zone: _ Outside Flood Zone? Municipsl O On site dispostl sys�em ❑
Public O Private O Chcek i( es0
. SECTION 2: PROPER7Y OWNERSHIP�
2,t wner�o(Record: ;n � CL� �� �'y--
x , ryt— �x
Name rinp Addreqss for SGervicc � ��/
/ �o � �� � (�
Signa�we Telephone
SECTION): DESCRIPTIOIV OF PROPOSED WORK�(check dl that rpply)
New Construction O Existing Building O Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition O
Demolition � ❑ Accessory Bldg. ❑ Number of Units_ Other O Specify' �r
Brief Description of Proposed Workl: L. � T�e 4^
X �ra e„� !a�'x �T!`' r-� �y'��'
SECTION/: ESTIMATED CONSTRUCTION COSTS
Estima�ed Cos�s: pm���� Uee Only
�1Q1^ Labor and Materials
I. Building f 2 � ,�d v I. Building Permit Fee: f Indicam how fee is detertnined:
❑Sundard Ciry/Tow� Application Fee
2. Electncal f O Tonl Projcet Cos��(Item 6)a multiplier x
J. Plumbing f 2. Other Fees: f
i. �techanical IHVAC) S Lisc
t .Nechanical (Fire S Total All Fees: S
Su ression
,.� Check No. C eck Amounl: Cash Amount:_
- 'x 6. Total Projec[ Cosf. S y ,,c�� aid in Full �Ouutandmg Balance Due:
G//s v 1 W '`�M �(�f►a'�''1
_ '
SECTION S: COIVSTRUCTION SERYICES
S.I Licensed Comtructlon Super��isor(CSL)
.,
' ' Li.eme Number Eepir��ion Dwe
N;yoe ol CSL HplJer Lui CSL T
� YG�B¢c h.low)
AJJrcss T' Drscn uon
U Unrestricted u ta)5.000 Ca FI.�
S������ R Rrstncird I&2 Pamd Dw�ellm
N Mason Onl
RC Revdenual Roofin Coverin
TAephone WS Residem�al Window and Sidm
SF Residemul Sohd Fuel Bumin A limce Insullauon
D ResiJentul Demoliuon
S1 ReQistered Home Improvemeat Can�nctor(HIC)
HIC Company Name or HIC Rcgrsrcant Name Rcgistra�ion Number
ACdrtss
Eapinlion Date
Signaturc Telephone
SECTION 6: WORKERS•COMPENSATION INSURANCE AFFIDAViT(M.G.L.c. 152.S 25C(6))
Worken Compensation Insurance andavit mus�be completed and submined with this application. Failure to provide
this afTidavit will rcsult in the denial of the Issuance of the building pertnil.
SigMr1 ARdavil Altached? Yee .......... ❑ No........... O
SECTIOIV 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S ACENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�• , as Owner of the sub'ect ro
� p perty hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building pertnit applicatioa �
Si nature of Owner Date
SECTION 7b:OWNER� OR AUTHORIZED AGENT DECLARATION
�• ,as Owner or Authorized Agent hereby dedare
[hat the statements and in fortnation on the foregoing application aze true and accurate,to the best of my knowledge and
behalf.
Print Name
Signaturc otOwner o�Authorized Agent Date
Si ncd under�he ains and nalties ot r�u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hire�an unregistered contnctor
(nol registered in ihe Home fmprovement Contracror(HIC)Program�, will�have access ro ihe arbitration
program or guaranty fund under M.G.L. c. I42A. Other impon�nt in(ortnation o�the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regula�ions I IO.R6 and I IO.RS, respec�ively.
2. When substantial work is planned,provide the in(ortnation below:
Toial Ooors area(Sq. Ft.) � (including garage, finished basemenVattics, decks or porch)
Gross living area(Sq. FI.) Habiiable room count
h'umber o(�replacee Number o(beJrooms
Number of bathrooms Vumber of halGba�hs
Type o(heaung sysiem Vumberofdecks/porches
T�pe o(caoling system Enclosed Open
�. "To�al Pro�ec� Syuarc Footage"may be.ubsututed for'To�al Pro�ctt Cost"
DEED REFERENCE: �
BOOK 10261 PAGE 117
. � . � . . . �NOFy,(r .
N�F LOT 100 0—, �'��� �
DAVID RUSSO � �:: �'
MAP 3 LOT 122 � 2, 369 f S. F• �9FC�T�P��
+NasvrrvE.�
(s�ij 86�89� "I CERTIFY THAT THE DWELLING
nl IS LOCATED AS SHOWN."
• __w /�� �.�
—� -----
�+o RALPH W. REID P.L.S.
�
%;,
,;
' N/F r�no `1 N�F
AGNES F. GEORGE 12'0 , .: ,: � TANNER BUILDINGS
MAP 3 LOT 123 (se j k 1 STORY � c`D.� MAP 3 LOT 127 GRAPHIC SCALE
� ", i m o �s w eo �m
r WOOD oi
o • �� �y,
� r-
� -:, �7.2' ( IN EEET )
STAKE � 1 inch = 30 ft
(aet)
I SALE M , MAS SAC H U SETTS
�� PLAN OF LAND PREPARED FOR:
, ST,�E I MARVIN 8c VANESSA DOLLINS
��°`� �s.00'
MAP 3 LOT 124
_ REID LAND SURVEYORS R
365 CHATHAM STREET D ��
6 CLARK STREET LYNN, MASSACHUSETTS
S96-041
�TS DATE: JUNE 18> 1996 SCALE: 1 " = 20'
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