7 CONNERS RD - BUILDING PERMIT APP l� O - I - 132 cA< 910015 3 $g9ob
The Commonwealth of Massachusetts ,
Board of Building Regulations and Standards RE EIVE(DTY OF
Massachusetts State Building Code, 780 CMR INSPECi10 4AL 5
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish-a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I Date pp)ied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I Cr�nr� n(`s 2oal 3kA 3(o - 03N - D
L Ia Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information 1.4 Property Dimensions:
Zoning District Proposed se ( Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
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❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.60 of Record: 1 / , 1 c
Name(Print) I City,State,ZIP
:� Cotno" e q-+o - 4,Aq-3s-o
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Buildingla' Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other OSpecify: Gt e A
Brief Description of Proposed Work': — 0 T
C �yn vac, c
� Cared . SE,tA 14tt&L_ c,S�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 6, a oI 3,J o I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
• 'r
4.Mechanical (IfVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ (p r aGj 3.vo ❑Paid in Full ❑Outstanding Balance Due:
(1)Qo t � 1 13 Ps(QOi2g(Zt So" $ I 1 Ct
t r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
. 9oi1s-
��j to-b- �y
��� I t tO�r�n' License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
&A t`�tnl-
No.and Street Type Description
I la nA 0�C/�- b\� oS U Unrestricted(Buildings u to 35,000 cu.ft.
l. t R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
SO
Solid Fuel Burning Appliances
SO$-a n l y I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
QPn4 L'JOA ) a..,�� —Aet \C^ HIC Registration Number Expiration Date
HIC C mpany Name or 1�Re istrant Name
30 ��� oa�
Mtree1 Email address
cu�l M(A 153a ,SO'8-3SI-do I y
City/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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 .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR
^BUILDING PERMIT
I,as Owner of the subject property,hereby authorize _ �G�! e 1 • ,o✓, r�
to act on my behalf,in all matters relative to work authorized by thA building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name bet ,;i1he by attest under the pains and penalties of perjury that all of the information
contained in this applic ion a and accurate to the best of my knowledge and understanding.
Print Owner's utho ed A s Name(Electronic Signature) DI atb
NOTES:
1. Own who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
of gistered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
gram or guaranty fiord under M.G.L. c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"