21 CROSS ST - BUILDING PERMIT APP (003) L T') Lf 2 c�,K IAA
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. The Commonwealth of Massachusetts cc,
1_ 9 Board of Building Regulations and Standards a' �C ��AI R ALEM
t + � Massachusetts State Building Code, 780 CMR *15R
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�Q Building Permit Application To Construct, Repair, Renovate OibbtnMl
One-or Tito-Family Drvelling
I ?his SeMion For.OlFcial Use Only
Eluiiding Fennit Number. Dat _ ppile�d:, .` `
Building OtTicial(Print Name) ;S�gnalure: J Da
SECTION 1:SITE INFORMATION.'
1.1 Property Address: IZ Assessors Map&Parcel Numbers
1 C roSS Sf
I.1a is this an accepted street9 yes no M1fap NumberNumber
1.3 zoning Information. IA Property Dimension ["
`Coning Disuict - Proposed Use - Lol Area(sq A) °Fron ge'(R)?N
1.5 Building Setbacks(M
Front Yard - -_- side Yards - - Rear Yard
Required - Provided Required P.rovided.. . . � Required�� � Provided-
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Informntlow 1.8 Sewage Disposal System:
Zone: Outside Flood Zorre7
Pabllc O Private a.- — Municipal Cl On site disposal system O- .
Cheek if esQ. -
SECT[O)V3::PROPERTY OWNERSRIP�. .
2.1 Ow,,,({�r�"err of Record: pO
17�me Print) - -City,soft,ZIP - .
No.and Street - Telephone Email Address
SECTION 3.:DESCRIPTION OR PROPOSED,WORK=(check all that apply)`
New Construction O it Isting Building O Owner-Occupied O 1 Repairs(s) O I Alierat(on(s) O Addition O
Demolition O AccessoryBldg.O . NumberofUnits_ Other O Specify:
Brief Description of Proposed%Vork':
aR
SECTION 4:ESTIMATED CONSTRUCTION COSTS : .
Item Estimated Costs: Of vial Use Only
Labor and Materials
1. Building S 1. Building Permit Fee:f Indicate how fee is determined
2. Electrical S O Standard Citylrown Application Fee
o Total Project Cost'(Item 6)s multiplier x
3. Plumbing S Li Qther Fees: f
4.Mcchanical (FIVAC) f list: e
S.\fechanic:d (Fire 5
Suppression) Total All Fees:S
/!AD` Check No.J�flCheck Amount: Cash Amount
6.'fotal Protect Cost: 3 lyvW . .� ❑Paid in Full ❑Outstanding Balance Due:
pnra,t_I�D To c . 5 zs I rJ S P"
SECTION 5: CONSTRUCTION SERVICES t
5.i ConstructionSopervisorLicense(CSL) g79-7 7 tilZ 311 S-
f c„ - License Number Expiration Date
Name of CSL Holder '' {} sl..,^ List CSL'rype(see below) -
3 Hilton Etreet TY ,. +,-. Description
No.and Street CBI _ U- UmextricteJ Duildtn u -to 35 000 cu.Il.
R Restricted I&2 Famil Dwelling
Cityfrown,State,ZIP _ M Mas '
RC Roo in Coverm
' WS WindowondSidin
/,� G 22 SF Solid Fuel Burning Appliances
1-7C" l�7 1f — p/(•t J I Insulation
Telephone - Email address D Demolition'
5.2 Reg(steredHome improvement Contractor{HIC) 3 /Z
tlggttC WCathenzatton,L. HIC Registration Number Expiration Date
HIC Company
No.and Strut Email address `
Cityrrown.State ZIP Tel hone
SECTION 6-WORKERS'.COh1PENSATION:INSURA(VCE AEFlDAV!F(tN:G,I: c+ISL g 2547(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 Isluanre qMe building permit
Signed Affidavit Attached? Yes......... No....:......O
y . SECTION7a;OWNBRAUTHO. ZATION.TOBE.COMPLETEDWHEN? .',
OWNER'S AGENT ORCONTRAC•fORAPfPLIESFOI!BUILDIN4 PERt4I1T'
1,as Owner of the subject property,hereby authorize ( ✓ G ��/�'''
rk authorized by this building permit application.
19 act on my behalf,in all matters relative to wo
y
Date .
Print Owner's to(Electronic Sign rc)
SECTION 7b:OWNERt ORAUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained-in this,application is a and accurate to the best of my knowledge and understanding.
70
Print Ovmer sor�whorizeJium�(EI Drat Signature) Date
ra
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("IC)Program);will rro have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Otherimporttan nfd ation on the H1Cl'rogra— m can be min
rvw+v meus.eov'oca Information on the Construction Supervisor License can be ibund at www•.naass.^ov;dos .
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. R.) • '+ (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
). "Total Project Square Footage"may be substituted for"Total Project Cost"