19 CONANT ST - BUILDING PERMIT APP The Commonwealth of Nassaehusetts
{ � Board of Building Regulations and Standards CITY OF
Y1 MassachtlSCUS State Building Code, 730 CLMR S Ravi A Mar
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
'this Section For Offi Onf
Building Permit Number; . / ate App
it
li
Budding Official(Print Name rgnature Date
SECTION INFORMATION.
1.1 Property A r. 1.2 Assessors Map& Parcel Numbers
1,1a Is this an accepted street?yes no, Nlap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(1t)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided. Required Provided
1.6 Water Supply:(I1.01 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewoge Disposal System:
Public❑ Private❑' Zone: _ Outside Flood Zone?Check if yesCl Municipal❑ On site disposal system ❑
SECTIONZ:; PROP.ERTII'OWNERSHIPt '.
2.1 Ownerro cor
Name(Print) - City,State,ZIP
6y` Coly -
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW'6beck all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTRNL4TED COIYSTRUCiTION COSTS-
Item Estimated Costs: OfR lai Use Only...
Labor and Materials y. .
I. Building S I. Building Permit Fee: Indicate how fee is determined:
�. f ectrical S ❑Standard.CityiI6tvn Application Fee•
Cl Total Project Costs(Item 6)s multiplier x
3. Plumbing S J, tither Feat 3
1. Mechanical (IIVAQ S List: .
i. ,Mcth.utic.tl. (Piro
1b1a1 All Fees:.$_
Check No. _Check Amount. Cash :\mount•.
I'ntul I'rnjcet ('nit $ ---
` � � ❑ 11.141 in Pall ❑Out.iCtudima IS;dnnce I)u0;
r ,
SKTION 5: C.ONs•r1tucrlON SERVICES
5.l Construction 'It ervisu •cense(CSL)
License umber 41GIOZ11 u�
N;rmt ut'—CS.L I folder — List CSL Type(see below)
Typt Description
No. an, Street�� ^^�" t /! U Restricted
1 Duilln' s u el 15,000 cu. tt.
R Restricted I,4r2 Famil Dtvellin
State, ` !P — — M �9asonr
Citylfuwn' RC Rooting Covering
WS Window and Sidin
SF Solid Fuel [turning Appliances
[ Insulation
lb t Mont
Email address U Utmolition
5.2 Registered Home Im rovetrtent Co ctor(11[
HiC Registration umber E. it tun Tate
l IIC ' a e I is m atne
Email address
No.a t
City/Town,State ZIP Ttie hone
SECTION 6: WORKERS'COMPENSATION INSUPANCE AFFIDAVIT(M.G.L.C. 152.1 2SC(6))
Workers Compensation Insurance affidavit must be comp ted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance a building permit.
Signed Affidavit Attached? Yes ..........Er No...........❑
SECTION 7a:01VNER AUTHORIZATION TO BE CO(yIpLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLES FOR BUILDING PEILViIT
r, as Owner of the subject property,hereby authorized
to act on my behalf, in all matters relative to work authorized by this building permit application.
Date
Print Owner's Name(Electronic Signature)
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 an acc ate to a best ofmy knowledge and understanding.
art
Print Owner's er AuthuriteJ:\;att's Nat a( •lectrunie Jignaturo)
NOTES:
Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will!tat have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the H(C Program can be found at
w ww m:us.euv%oca it,formation on the Construction Supervisor License can be found at www.mass.y ti%:d
2 1Vhen substantial work is planned,provide the information below:
(;q. ____. _(including garage, tinished basetnent/attics,decks or porch)
Total flour area ttJ
tiros; living area Oil @.l Number o men count
_
Humber of tireplacc;_ -------— Number of bedrooms -- ---.____---____--
vuvther of hathromns .--_-__-- Number of hal6baths _--_.._----
Numbenrf .-----
--
fI,,rill'rq:rt ��luual ,Le;a'' in.tyhc ;ub,tinu;dt;,r"I,-t.ill'njddl',r;t'--- -