17 CONANT ST - BUILDING PERMIT APP ��•00
4
The Commonwealth 0f MaSSaChIISCltS
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNfR SALLAI
i
Building Permit Application To Construct, Repair, Renovate Or Dcm ish RNrivv.l.l6ir ll/
One-or Tnvo-Furnill Dn elthkq
This Section For Official Use Dill
Building Permit Number Date Applied:
Building Print Mane) t� Signature Dute
SECTION I:SITE INFORM ION
1.1 Propertyx Addres : 1.2 Assessors Map& Parcel Numbers
l'7 Canes_7 Sa(
I.la Is this an accepted street?yes_✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Ana(sq 11) Fmnlage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Requim-d Provided
1.6 Water Supply:(M.G.I.c.JU,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public lr� Private❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal B n site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
Navic 'r City.Slate.ZIP
11 tl-//OOP'"Ow 71" 9�g,•66-�996
No and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Spccily:
Brief Description of Proposed Work':
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estinta(ed Costs:
(Labor and Nlaterials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical g ❑Standard City/Town Application Fee
i. Plumbing g
❑ 1P Total Project Cush(Item 6)x multiplier _ _—x _-.---
_. Other Fees: S
J, Mechanical IMAC) S
-i \Ievilalllcal lFirc ------- - -------- -
Suppression) S 'rotal Ali Fees: s - ------ ----
b. Total Project Cost: S j1,6—pd, Check No. ---('heck Amount: - -------Cash Amount:
❑Paid in Full ❑(Jut ❑nJing BAimee Due:
o .
SECTION 5: CONSTRUCTION SERVICES
5.1 Constr/upction Supervisor Liceuse(C'SI,) /
y �� ._.__—_ Licmise Nunlher f\lirWiou D;ne
Name oft SI. Holder
Lizt Ctil.1')pc(see helusvl —
i3_�cotrt �__l��CI.)Pe I)egcriplion
No. ;old Street
tl tInrestricled(Bwldin gs up to 15,000 cu. 11.)
R Re,lricled 1,2 Family Dllcllin
Cipi full n,Slm• LIP NI NfasonrY
RC Roulin C•oeerin
_..—._ N'S Window and Siding
h Solid Fuel llurning,\pplianceg
1O ��, n e 1 Insulation
"1'ele hone [:mail address D Demolition
5.2 Registered home Improvement Contractor(HIC)
4p Cs �,, h h" • f+w`T� I IIC Registration Number Fspimniun Date
I IIC C•lmpan) Name or IIIC Ito istr•nl Name /
3 CCJl^nr-/i �� /YirlrisC's//�O@�on+cas •nr
N ld Street A _S 30� Email address
Lev ey sT / L
Ci /Town fate, ZIP "felt 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 affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... (M� No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1• 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.
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 accurate to the best of my knowledge and understanding.
*1'CIac/ DejS ,,a// UZ!F,, //
Print Owner's or:\ulhorired Agent's Name I flcctrunic Signature) Dale
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 Hume Improvement Contractor(HIC) Program).will n0 have access to the arbitration
program or guaranty fund under I.G.L.c. 112A.Other important information on the HIC Program can be found at
w\o ma,, „1 o, I Information on the Construction Supervisor License can be found at I%%\ll.nla,c o� 1p,
2. \\'lien substantial work is planned, provide the information below:
Total flour area tsq. ft.) _ --_1 including garage. finished basement'attics,decks or porch)
Gross living area(sq. tl.l " __._ __-.- - Habitable room count
Number of fireplaces_---- Number of bedrooms
Number of hathnwnls __ Number of bolt bads _
N'umberofdecks, porches. ..__... ._
1\pe of cooling i\stcIll - _ .. Enclosed _ _ - " - 011en
L1, -Folal Project Square Footage- ma) be suhstinned for''fotal Project Cost-
J