41 COLUMBUS AVE - BUILDING INSPECTION (6) cr-- jogs Cz P ��
— - --
7, I'he C'omwm ns'euhh of Massachusetts
i.1 Board of Buildin b Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALENI
'L,,•• Re ri.reJ I htr_'ll l/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-ur rnw-Frill'•Diiv linX
This Section For 011ricial Use Only
Building Permit Number. all Applie (o _
Building Olticial(Print Mune) Signutu r Oule
SECTION I:SITE INFORMATION
1.I Property Address
✓nyr�•u:1 1.2 Assessors Map& Parcel Numbers
�l Coo
I.[a is this an accepted street?yes no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Tning District I'rupuscJ Llic Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
F,16
equired Provided Required Provided Required Provided
ater Supply:(M.G,L c.JU•§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
❑ Private❑ Lune: _ Outside Flood Lone? Municipal❑ On site Jis
Check if cs❑ P pusul system 0
SECTION 2: PROPERTY OWNERSHIP'
2,1 Owner'o(Re d
_N/e�tgPil obb18
Name(Print) City.Stale,ZIP
yy �n7
No.and Street Telephone _ Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner•OccupiedX Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. Number of Units Other Spwit'y:
Brief Description of Proposed Work=:
SECTION J: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs:
(Labor:nd Materials) 0mcial Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6).x multiplier _ x
j ?. 1'lumhing S '. Other Fees: S - _----
a,:\Ixh;utic.d III\'.1(') S List:
' S. \IcrIedh:wicul Wire ------ --------- ----- -..
'isio S Total .Ill Fees: S -- --- -- __._. .
Cheek No. ('heck Annnml: __ ('ash Amount: _
o. Total Project Cost: S40a), ❑Paid in Full O outstanding Balance Doc:
SE("1'ION 5: CONS"1'RUcTION SERVICES
5.1 Construction Supervisor License(C'St.) Of—
A".v - — —Zhate� �- LicenseNulhcr f Dana
\;unc ul l'SI. I IulJar
I istC'SL
_—_____—.-_____________ T}pe Description
N,t. and Strccl
6>/J'7 I[ I Inrewrielcd I ffuiWin�s li to iS,1111U cu It.
OU/1 --.,— ---.. . . It Restricted 1r2 Family Mwllin
Cilyil'oall,.state.LIP M "lsunry
KC' Rix lire Covering
---- WS Window and Siding
SF Solid foul fluming Appliance$
97� zu/�yr� Insulation
I cle hone Fwail address D Demolition
5.2Registered flume Improvement Contractor(HIC)
q�
V'°A-y W�N� '(Z ��N rw(:�- I IIC Registration Nmnher lispir don Date
I IIC mp N me ur I IIC gis am Nunn
Nu.�annd( } � 97d-zy13y7, Einuil address
City/Town. State,ZIP Telc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.4 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 Is uance of the building permit.
Signed Affidavit Attached? Yes....... No........... 0
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize Ac yl w �j'L
to act on my behalf,in all \alters relative to work authorized by this building permit application.
61,�P � 111
I'rin Owicr's Name(Electronic Signature) ate
SECTION 7b:OWNER' 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 accurate to the best of my knowledge and understanding.
Print Uencr's ur:\nduuired Agnt's Nnnte I lilectrunie Signature) uta
NOTES:
I. :\n Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(nut registered in the Hulse Improvement Contractor(HIC) Program).will nrr 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
eeo n1.11, o,I Information on the Construction Supervisor License can be found at +>++s m-i,; >:,% dp,
2. \\'hen substantial Iwrk is planned,provide the information below:
Total flour area(sq. R.) - I including garage, finished basement attics,decks or porch)
I, Gross liv ing area uy. it.) _-_ -.--_ __..- - -. Habitable room count
Number of fireplaces__. Number of bedraums
I `umber of bathnwnu \'umber ul'hall'baths
_ I
I}pe of heating sy stem .. . _ _ Vunthcr ofdecks, porches
I\lie of Cooling S."IC111 I!Ilclosed Opelt
1. "focal Project Square Fa,nuge"nt:ry he substituted Illr"folol Project Cost'