12 CRESCENT DR - BUILDING PERMIT APP (002) t the Conunon\\ealth of Md.SS:1Cht1Selts I
It Board of Building Regulations and Standards I'uR
\I
"' t-NII�II'.\I II1
MassaChuxus State Building ('ode. 7SB (•MR. 7 edition I SI.
Building Permit Application To Construct. Repair. Reno\ate Or DenioliNh a Rr nrJ Lurri n
One- of Tnru-hiunily D+rrlling
i
This Section For Official Use Only
BwlJine Permit Nunn Date Applied:
---
n:uarr:
Budduig COImn1+VOner cuu of Buildings
SECTION I: SITE INFOR:MA'1 ION
I a 1�I .. :ur"�pf �ese[t 'p N.--._._
1.1 Pro erts ddress: 1._ assessors Ma @ Parcel Numbers
.. r M1ia i\'umhrr P.u.a X'unhrr
1.3 'Lca3r.� lri�3rtrc:iuu: "i.4-Froperty bime:isiun,:
Cep --- — — -
Z
oning
ng District Proposed Use Lot Area(sq lit Runlage eI li)
Building Setbacks (ft)
From Yard Side Yards Rear Yard
! Required Pnnided Required Provided Rcquoed Pin" ded
1.6 Water Supply: (hA G.L c. 40. §54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Zone: Outside Flood Zone? Municipal ❑ On site dis sal e iem ❑
Puhlic ❑ Private❑ Check it yes❑ p Iw ys
SECTION 2: PROPERTY OWNERSHIP'
i
2.1 Qwner of Record:
41 MIA s
N.une i Print) .Addiess lox Service:
_ 5'71 Zyy-,[>'2 / L/sr -- -
Ltiicn:•turc
SECTION J: DESCR;'T1ON OF PROPOSED WORK Z(check all that apply)
`!ew Construction ❑ Existing Bwf�ine u i!\c^er-Occupied Rep:urs(s) ❑ Alterauonls) r\ddilirm ❑
Deme!iGon ❑ Accessory' Bldg. ❑ ?4umb-n of Units Other ❑ Specify. I
Brief Desu'Iptiun+ f Piop•rN, d 'X4irk,:_ Q.ca-�` —I.U_�J PC'_ - '✓ t'2-h'r—�Z---
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (1_aMx and M:uerials) Official Use Only
I. Building S ..- 1.
Building PermitFee: 5 Indicate hu++ fee is deler nursed
XStandard City/Town Application Fee
?. Electrical 5 ❑ Total Project Cost' (Item 6) x multiplier x _
1. Plumbing S 1. Other Fees: S
4, Mechanical (HVA0 $ List:
5. Mechanical (Fire ,�
Suppression) : Total All Fees: S
Check No. Vq).Check :\mount: ( a.h \mrrunl:-- _ -
b Total Project Cost: SS aid In Full 0 OutstanJlnrr Balance Due:_ _ _"-
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor IC•SI.f
sjr-
loo��
.yv l.lccn>c Nlunhcr I[sl Lluun lair
Naloc of /�CSL" Ilo Jer
.ul CSI_ f_,pe Lee heluo 1 __.._
"fv r Dr..rt ,Ilan
C ( IIrt911'ICICJ Ili+ IU \i.IN)O CU. l'1 i
- R - RcslncleJ L@2 F.mtdk Dwclllne —�
tit astute /
RC R —�
—
eslJr n lla R uo ti n c Cmitlne
I cIcphonc \\S RCNIJilnldl \% nJo++ ,wJ
SP ReNtJcuILJ Solid 1-ucl Buluu�e \_ + +l i,in._111,1_JI roil,
D ReNIJ:nlial Ocnwl't"'It
5.2 Roister (torn [prove t Contruclor (1 IC)
11IC Co n .Nat •ar it Ree it( Na a1v Registration Nunthcr
V t
A Jre e —
F..poati,+n Dale
Sap tort Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 2506)1
Workers Compensation Insurance affidavit must be completed and submitted with [his application. Failure ❑+ proude
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached" Yes .......... ❑ No ........... 0--�
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. as Owner of the subject property herebv
authorize to act tin my behalf. in all mat[ers
relative to wotk authorized by this building permit application.
Si nature o['Owner Date ----------- —
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, • as Owner or Authorized Agent hereby decLoe
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Si ned under the 2ains and penalties of e(u .)
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an Lint eel C++ntra,11
TI
(not registered in the Home Improvement Contractor(HIC) Program). will not have access to the arbin a[lon
program or guaranty fund under M.G.L. c. 112A. Other important information on the HIC Program ;Ind
Construction Supervisor Licensing (CSL) can be found in 780 C MR Regulations I I0.R6 and 1 111.R5. respectively
' When substantial work is planned, provide the Information below:
Total tLotrs area ISq. Ft.I (Including garage, finished ba.sc rlent/atrics. decks Ir ptrrht
Gross living area t Sy. Ft.) Habitable room count
Number of ttreplaces Number of hedrooms
Number of bathrooms Number of h.11t/haihs _----------__---_ --
kpe of heating system _ _ Number of decks/ pt'nhcs
Type tit cooling Sy>tenl
1. "Total Project Square Footage- may be substituted tirr roial Project Cost- _ll