3 CROSBY ST - BUILDING PERMIT APP - a
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Code, 780 CMR 7ditionm OF SALF.M
t Massachusetts State Building oe, , e
Revised Junusiry
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• -0014
One-or Two-Family Dwelling
is Section For Official Use Only
Building Permit Number: Date Applied: �Q
Signature: -dr
Building Commissioner Spector of Buildings Date
SECTION 1:SITE INFORMATION
I.1 Property Address: 1.2 Assessors Map& Parcel Numbers
- 5�Y ST-
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 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I,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 ycsO
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: ; l
sGlG R.� a.✓ OY 3 Ct20SID�( �T
Name(Prim) Address for Service:
9-1 R `7 4 S� o
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building-B'- Owner-Occupied Repairs(s)CjijAlleration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': 777e r,z , n
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated CostsrTotal
Official Use Only
Labor and Materi
I. Building T 0 3 Q(r) ermit Fee:T Indicate how fee is determined:
ilyrrown Application Fee
2.Electrical Tr
t Cost (Item 6)x multiplier x
1. Plumbing T . T4.Mechanical (IIVAC) S
5. Mechanical (Fire S Total All Fees: T
Suppression)
�7 Check No. Check Amount: Cash Amount:
6.Total Project Cost: 5 0 Paid in Full ❑Outstanding Balance Due:
r _
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 9 "4-1 / t-(- y
License Number I xpimtion Date
Name ol'CSL-I lulder �-y
-�3`2 S C.n A�9(i List CSL'type Ilea below)
Add s r Description
♦ �c Q U unrestricted(up to 33.000 Cu.Ft.
R Restricted 1&2 Family Dwellin
Sig uturc M Masonry Only
RC Residential Routing Covering
relephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regbt'red Home Improvement Contactor(HIC)
!IIC Company Name or HIC Re 1�stranI Name �7 Registration Number
Z'3 i2 UJ
AJJ
! _?�s�— S 3 Expiration Date
Signature Telephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.¢ 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 Issuance 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
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.
Si Lure of Owner Date
7 SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
G 'k 0 b tip- ,as Owner or Authorized Agent hereby declare
re that the statements and information on the foregoing application a true and accurate,to the best of my knowledge and
behalf.,
Print Name
Signature of Owner or uthorized A eat Date
(Signed under the pains and nallia o 'u -
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 VJ have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/anics,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"
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