12 CONNERS RD - BUILDING INSPECTION (3) 10t �
The Commonwealth of Massachusetts CITY OF
en i Board of Building Regulations and Standards 1plb DEC 13 CAM
Massachusetts State Building Code,780 CMR
Revise)blar 20l l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
G�j N N pfLs One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: Date Applied:
I� Iz1
building Otticial(Print Name). : - Signature _ - Date
SECTION 1:SITE INFORtAVIAT1W
1.1 Prop rty Address:�II 1.2 Assessors Dlnp&Parcel Numbers
12. �irWl�S F�l
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq t1) Frontage(11)
1.5 Building Setbacks
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 O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION2: PROPERTY OWNERSHIP"
2.1 7nera j ca�aem l,i A
I�t1me(Print) City,State,ZIP/
12 C.onne(s Rya Sob 46 5-jqs
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORM'(check all that apply)
owner-Occupied ❑ 1 Repairs(s) ❑ 1 Altera ❑ ❑tion(s) Addition Con:stiruction�13E.xisting Building C3n
Demolition ❑ I Accessory Bldg.❑ 1 Number of Unit_ Other ❑ Speedy:
Brief Description of Proposed Work-: 97rcx-ir� WC
a S
KMDv�S f"C�'>\G•�•C. i,reg"lc `►" �r4,n►\ feilt�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
I(cm Labor and Materials) -
1. Building S'77 5 G I. Building Permit Fee:3 Indicate how fee is determined:
❑Standard City/Town Application Fee
2, Electrical S ❑Total Project Costa(Item 6)s multiplier s
3. Plumbing S 2. Other Fees: S
4.Mechanical (FIVAC) S List:
5.:\lechanical (Fire S Total All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:_
6. 'rutal Project Cost: S 77].SG ❑Paid in Full ❑Outstanding Balance Due:
S ic> TL7 Z® Sc—TNJt��
2 t
SECTION 5: CONSTRUCTION SERVICES r)
5.1 Construction Supervisor License(CSL) CS--ro,L?y31 S/ V/7
k-k�I II Gr^ 4C,1r4 M License Number Expiration Date
Names o'ffCSL Holder List CSL'rype(see below)
rL
' `—' Pc.,Aaj T - Description
No.and Street '
km JMG U1 k5U Unrestricted 1. 2(Buildingu el ing w. it.
R Restricted I&2 F;unil Dwelling
City/rown,StattZIP WIMI�IV4,asonry
Coverinand Sidin
`� 1l Burning Appliances
10`�-V Tcle hone Email address n `
5.2 Registered Home Improvement Contractor(HIC) w2q%--
FIIC Registration Number Expiration Date
f itumpaa Namg or 111C Registrant Name
Y, G G�cbu�C
and Street -7p r? 7$)) Email address
D
City/Town, Stdte ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFBIDAVIT(M.G.L.c.157:§ 2SC(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 Is§uance of the building permit.
Signed Affidavit Attached? Yes .......... O No...........O
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
t9 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 licatio true and accurate to the best of my knowledge and understanding.
Print Owner' r Authorized Agent's Nanc(Electronic Signature) Date
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 no have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
wVww.m3ss.11ov'oca Information on the Construction Supervisor License can be found at www•.mass.,,ov'dus
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Grass living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Typeorcoolingsystem Enclosed Open
i. "I'otai Project Square Foolage"may be substituted for"Total Project Cost"
12/5/2016 Resized_20161129_092834.ipg
a r
—46
a n
a r e
x
4�F_�C �'',.c dy -c ✓A s �'T"' s a4 w w -. .{y�. g rot�mF� �' 1+3°.w
4,41
%2 ^
n
t
Ip
q h,
• ' a w4 �'
f _
x F
KL
�s
� `µh
w
a .m
$x1
Al
https:l/mail.google.comimail/u/Ofts rchAcennethdalexander°/o40msn.com/168h6D40407f52?protector=l 1(i