48 CLARK ST - BUILDING INSPECTION (4) - - 1u - 11KZ � BZo � 2ED
_r The Commonwealth of Massachusetts IN5PECTIONAV SERVICES
CITY OF
Board of Building Regulations and Standards �p�'p��LE��Mr�tr
II / Massachusetts State Building Code, 780 CNIR Re9li"A11770f Ali: IS
� Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only '
Building Permit Number: Date PPlied:
BuilJing Olticial(Print N:une). - Signature Date
SECTION L•SITE iNFORNIATION`
1.1 Pr perry Address: 1.2 Assessors NIap& Parcel Numbers
L'LA 2rG Sr
L I a 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 it) Frontage(It)
L5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§5J) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes13
SECTION2: PROPERTY OWNERSHIP!
2,j5 wnerl of Record:yhme(Print) City,State,ZIP
SrT r7fr l-9&�-S22
No,and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) dr, Aitemtion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': - '
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Buildin; Qpc7 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard CitylTown Application Fee
?. Electrical S r ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S r— P 9ther Fees: 5 / /,
d. Mechanical (HVAC) S List: '�'bn&
5. Mechanical (Fire S Total All Fees:S
Su ressiun)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: �Or ❑ Paid in Full ❑Outstanding Balance Due:
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Cuustruetimt Supet-visor License(CSL) .2l _ ,
y ' �. /�; •�,- C, 1 / f_ t ` License Number Expiration Date
DaatteL' -
Name ofCSL Holder —7.
List CSL'Type(see below)
+�— FoQw-- --� Type - Description
N .
o. ;aid Street Unrestricted(Buildings tip to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Cityll'uwn,State,LIP bt Mason
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address U Demolition
5..Z Registered Home Improvement Contractor(HIC) S.7B.,g��
—dA- /�l..�Uht/S HIC R/ugislra!Number Expiration Date
HIC Cum .my Name or HIC Registrant Name
nSR-ett 8 Email address
t,l�f [fit 32tate ZIPTele hone
ION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.LL c. 152.§ 25C(6)).
mpensation Insurance affidavit must be completed and submitted with this application. Failure to provide
t will result in the denial of the I_sivance of the building permit.
Signed Affidavit Attached? Yes ........ No........... ❑
SECTION 7a:OWNER A HORIZATION,TO BE COMPLETED WHEN' "
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERDIIT
1,as Owner of the subject property,hereby authorize b Ul A'�3�
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
&2�.
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
contained in this application is true and accurateto the best of my knowledge and understanding.
1'ritwiter's u$ r��\uthorized Agent's Nume(Elecuonic Signuuve) Date
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(1-IIC) Program),will fiat 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
+eww.mass.guv:'oca Informa w.mass.��o+�'
tion on the Construction Supervisor License can be found at w++ dns .
2. When substantial work is planned, provide the information below:
'total floor area(sq. ttJ (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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_
1. "folal Project Square Footage"may be substituted for,,Total Project Cost"