15 COLBY ST - BUILDING PERMIT APP r
1 I-lie Conuuumcealth of n'IJSSJChIINettS ---
* It, Board of Building RCgaIJtIUnS lllld StandardsIs
lll
MLINSUCIMSCUS State Building Code. 78I1 ('MR. 7 edition 1 'NI-.
\\\11) Building Permit r\pPll /)ntl hlT.,`tiTit�uu`tF'rr01t�wl/U'r`Only (r Or I)elnuli�h a R, � r.r� 1�,,,,,,n t
J,,ilding Permit Numher: Date .Applied: U 1
---U------..
nalure: __ y [J
13wldiuE
S ' 'TION I: SITE; INFORMATION
LI Pn>perly .\ddress: 1.2 Assessors Map & Parcel Numbers
I.la Is this an accepled stree(.' yes ❑t, Map Nuinher Pai,cl NWIIhC1
1.3 Zoning Information: 1.4 Properly Dimensions:
lumng Ouviet Proposed Use I.ot Area(sq it) Frunluge ilt)
i.5 Building Setbacks 'fry
a
Front Yard Side Yards Rear Paid
Required Provided Requited Pnry ided Requu;ed Prot 1110 —1I
i
1.6 Water SuplAy: (M.G.L c. 40. §5.1) 1.7 Flood Zone Information: LS Sewage Disposal System:
Private❑ Check if yes❑
Zone: _ Outside Flood Zone?
Public ❑ Municipal ❑ On .ite dis et
1 rrsuls sle ❑
SECTION 2: PROPERTY OWNERSHIP'
, Owner of Record:
1 It ri, ovia Le,i�rfie. LSCo [by S �'• i
J� 0.
V NLIMC(Pr:nt) Address for Service:
2 _ 9 7 F' 7 y l 0 --
Signature Telephone
SECTION 1: DESCRIPTION OF PROPOSED WORK'
(check all that apply
)
j iJcw Cunatructit�n ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alter:nion(s) ❑ \dJilion ❑
Demolition ❑ 1 Accessory Bldg. ❑ I Number of Units_ Other ❑ Specily:
Brief Description of Proposed
SECTION J: ESTIMATED CONSTRUCTION COSTS
E6lim ated Costs:
'rem Official Use Only
(Labor and Ma(eriJlsl
1. Buildine S 1. Building Permit Fee: $ Indicate hosc fee is determined.
❑ Standard City/Town Application Fee
[2. Electrical 5 ❑Total Project Cost' (Item 6) x multiplier xPlumbing S ' O(her Fees:. Mechanical (HVACI S List:Mechanical (Fireu i ress tool Total All Fees: S
Check No. Check Amount: ('.I>h Amount i
( otal Project Cost: S X00 0 Paid In Full 0 Outstanding Balance Due_____
SECTION 5: CONSTRUCTION SERVICES
5A Licensed Construction Supervisor WSL) _ C
Lot CSL, l\pr i src helaw I �
\Jdresr
1. l'nrrslnrteJ iutw ::.000 Cu I'ii
— --- R Reeoletcd L42 F.unl l\
1 Sign;nure >I Alu,+ono Uniti _ --�
- _—. KC itraJ:nlwl Kindine (',nainv
h<li phone AU I?.aJrnlial lA iuJ��„_.in,l liJiii� _ __ .
aJcnu.J Solid I .Iel ISmnul❑ \ _IL,$;it hi_Lil A1011, y
5.2 Registered Home Improvement Contractor 011C) — —
ill(- ('ump;uty Name or I-IIC Registrant Name Keglzuau,m .Ntjmhrr
\ddrese
P.spl rau,m Duty
Signature Telephone
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (M.G.L. c. is2. § 25C( )1
Workers Compensation Insurance affidavit must be completed and suhno tied .with this appl is athm. Fadure io pro\Ide I
this affidavit will result in the denial of the Issuance of the building permit. J
Signed Affidavit Attached'? Yes .......... Cl Nil
SECTION7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize __--to act Lin my behalf. in all m.utets �
;e!ahae to •xurk authorized by this building permit application.
Signature ut Owner —_--_ _Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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.
Print Name
Sienuture of Owner or Authorized Agent Date
(Signed under[be 12ains and penaltiesot ego )
NOTES:
I. An Owner who obtains a building permit to do his/her own work or ;m owner who hues an urneui.mred cmilrna,Ir
(nut registered in the Home Improvement Contractor IHIC) Program). will not have access to them hilr inn
program or guaranty fund under M.G.L. c. IJ2A. Other important intiormalion on the HIC Progr:un and
Construction Supervisor Licensing (CSL) can be found In 780 C'b1R Regulations 110.R6 and 110R5. respeclrsely.
2 When substantial work is planned, proud:: the information below
Total floors area (Sq. Ft.l (including garage, finished basement/attics. Jecks or purrh)
! (•bogs living area l Sy. Ft.) Habitable room count __-- --
Number of titeplaces Number of hedrrnans ------- -_---._-- - .
Number of bathml,ms Number of h,Ilt/h:uhs
hope of healing system __-- Number of decks/ pot.hcs
I.we of coo ing �S,aem __ Fnt lk,sed
1. "ilnal Project .Square Footage" may ha substituted tiRTotal Protect Cost"