8 CONANT ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
V { Board ul Building Regulations and Slandards CITY
/ y J Massachusetts State Building Code, 780 CMR- T"editionJ
\ t�
Building Permit Application To Construct, Repair, Renovate Or Demolish One-or Two-Family Dwelling
This S For ORcial Use OnlBuilding Permit Number: Date Applied•
Signature:
Huilding Commissioned In fbir Of ffk!dKDate
SECTIO :SITE INFORMATION
1.1 Property resjr n � 1.2 Assessors Map dt Parcel Numbers
1.1 a Is this an ace Itd streel?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq 11) Frontage(11)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Cheek if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own* t f ecor
fi g �N� .�n �.z A119r/b
Name(Pnn Address for Service:
Signature ITelephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check a hat apply)
New Construction O Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) < Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.O 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Use Only
Labor and Materials
I. Building S _ I. Building Permit Fee:f Indicate how fee is determined:
?. Electrical S
❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
). Plumbing S 2. Other Fen: S
4. Mechanical (11VAC) s List:
S. Mechanical (Fire S
Su ression Total All Fees:s
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 13 Outstanding Balance Due:
SECTION 1: CONSTRUCTION SERVICES
19.1 Licensed Construction Supervisor(CSL)
JRC
Name ol'CSI •I ul cr SL Type(aee below)
pescri ion
:\d Unrestricted u to)3,000Cu.Ft.Restricted Id2 Famil UwellinSi m '' ''�nn M:sson Onl Residential Rootin Coverinclephone Residential Window and Siding
SF Residential Solid Fuel Bumine Appliance Installatiun
p I Residential Demolition
3.2 Registered Home 1 proveme tract r_(HIQ
v
III Name j
C Registration Number
j-}I`735r �— Expiration Dole
re1ccphu
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL f 2SC(6))
Workers Compensation Insurance affidavit must be c plated and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc of the building permit.
Signed Affidavit Attached? Yes .......... CK No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I al , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Dote
SECTION`7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1jGIC l—!(I�yJ� as Owner or Authorized Agent hereby declare
that the statemenq and information on the foregoing application arc true and accurate,to the best of my knowledge and
behalf.
Prins ame
0 or Aur o zed Agcnt Date
Si r the eains and penalties of 'u
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(HIC)Program),will aw have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.R3,respectively.
When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage, finished basement/anics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half7baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed _ Open
). "Total Project Square Footage"maybe substituted for"Total Project Cost"