41 COLUMBUS AVE - BUILDING INSPECTION (7) I lie Commonwealth of Massachusetts
Board of Building Regulations and Standards Cl I'1'OF
st Massachusetts State Building Code, 780 C'MR SALH\I
'a•,.. ireri.ced llur 21)1r
Building Permit Application 'ro Construct, Repair, Renovate Or Denwlish a
One-or rirn-Funtiln Um elline
This Section For Official Use Onl
Building Permit Number: _ Date Applied: _
121 kt.) o I.Z544
Building Official(Print Mum) Signalu Date
SECTION I: SITE INFORMATION
I.i ProperxGvrr�Address: 1.2 Assessors Ala & Parcel Numbers
N/ <" UJ p
I.Ia Is this an acre ted street?yes n✓ o Zap Number Parcel Number
1.3 Zoning Information: 1.4 Properly Dimensions:
Zoning District Proposed Use Lot Arco Isq 11) Frontage 111)
I,J Building Setbacks(it)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munici al❑ On site dis
Check il'M. P posul s y stcm ❑
SECTION2: PROPERTY OWNERSIM
1.1 Ownera of Re rd: �1
Mttlnas 1 I�o M a Q d 7 0
Name(font) City,State.ZIP
Yl C'01-amyor Mom- Z I-3y7/
No.and Street Telephone Finail AJdress
SECTION J: DESCRIPTION OF PROPOSED WORKr(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ .Accessory Bldg.❑ 1 Number of Units Other Specit'y:
Brief Description of Proposed Work':
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Costs:J' ,Estiniated
bormtd Materials) Of IA Use Only
I. Building I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical ❑Standard City,Town Application Fee
❑Total Project C'ost'(Item 6)x multiplier1. Plumbing ' OtherFcc$ Sa. .Mechanic,d IIF List:— -
5. \IcJhaaical (Fire S — _---- .--- ._--_
Su,+ression) Total ,\it Fees: S
Ch"k No. ('heck Amount: Cash \mount:
e. Total Project Cost: 5 p � ° --- - ----
/ 77.3• ❑Paid in Full 13 Outstanding Balance Due:
A 0 old+/'x-q vle�
SE('TION 5: ('ONSTRUCTION SF.RVI('F.S
5.1 Construction Supervisor License(C'SL)
LKeWse Nuother
------------ --- -- - -
� --- �-� fspira iol Ilalc -
Nanc ol'C'SI. Holder
__._._._ list CSI.
3 __-__
� — '1\pC Description
No. and Street
tl I Inrestriaed I❑uilJin s ti to iS,I11W nl. Il.l
R Restricted IR3 FaIllilY Mwili,1
011. foes..Slaw./IP M Masonry
RC RtxHin C'orerin
VA Window amd Siding
p ^f SuliJ R FUCI flurning AppliancesInsululian
felt holes Entail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ///d 17 / /t /S
(n)�w r4L I IIC Registration Nunther E Ira l sun Dale
III(' omQQun u1 •'or I jjIC'Registrant None
No.: v••t �� '?7jr ']rd`7VI '�� Emuil address
City/Town,State,ZIP l (!! "relc hone
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 atlldavit will result in the denial of the Issuance 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
I, as Owner of the subject property,hereby authorize �e(yx-4
to act on my behalf,in all matters relative to work authorized by this building permit application.
Mido-4 44,�kr7 J 1. ,,
Print Owner's Name(Electronic Signature) /Datef
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
�accurate to the best of my knowledge and understanding.
f� /G l Ae-l' / / p /
Prim Os,ner's or:%uthorired Agent's Nat e(FIeclronic Signature) D' e
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 Hanle Improvement Contractor IHIC) Program),will rro have access to the arbitration
program or guaranty fund under.M.G.L.c. 1 42A.Other important information on the HIC Program can be found at
www ni.r•, o% o,.1 Information on the Construction Supervisor License can be found at
2. %%'lien substantial work is planned, provide the information below:
Total flour area tsy. a _ _,___""_I including garage, finished basement attics.decks or porch)
Gross It%ing area Isy. I1.1 --_- _ _._ . Habitable room count
fNumber of f ircplaces ..... _ _ Number of bedrooms
Number ofhathrooms Number of half hallts
i
I)pe of llcating s)slem Number of decks, porches
Is Ile ofeJtlhllgitstall/ Inclosed _ " -_I)pelt -
1, "Iol;ll Project Square FoolagCIltlly tic substiluted l'or"folal Project Cost-