21 CROSS ST - BUILDING PERMIT APP i
The Commonwealth of Massachusetts
W
OF
Board of Building Regulations and Standards CITY SALE
M
Massachusetts State Building Code,780 CMR
Revised Mar 201/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling j
This Section For Official Use Only
Building Permit Number: Date Appli
I
Building Otfcial(Print Name) — � � ignauac ��r��
SECTION I: SITE INFORMA'I ION
1.1 Property Address* 1,2 Assessors Map & Parcel Numbers
l.la Is this an accepted street?yes_ no Map Number Parcel Number
I..i Zoning information:,... -
Zoning District Proposed Osc tut Area(sq fl) Frontage(lt)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yar..
Required Provided Required Provided Rcgmrcd
1.6 Water Supply: (M.G.1-c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Sysicnr:
Zone: Outside Flood Zone?
rPublic❑ Private❑ — Municipal ❑ On site hspr
_Check il'vcs❑ -
SECTION2: PROPERTY OWN ERSH IP'
2.1 Owned of Record:
for ey --- — So
� IvIR 019-1 O- .._. _
Name(Prinq City,Stic ZIP
9_( Cndss -- — 9 7 YS-a--95-3 ---- __
No.and Street Telephone Email Address -
SECTION 3: DESCRIPTION OF PROPOSED WORKe(check all that apply) /�
New Construction❑ ) ❑Existing Building❑ Owner-Occupied ❑ Repaics(s Alteration(s) 13 I Alldi;iou C.
Demolition ❑ Accessory Bldg. ❑ Number of Units _ Other ❑ Specify:____ -
Brief Description of Proposed Work': Irn fi-fq, (l ./VQ�e3L_LGZ<r�dr'ri�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: official Use Only
(Labor and Materials)
1. Building $ ��"4 / I Building Pent Fee $ Indicate how to r-- i i r c -
— --— 0 Standard City/Town Application Fee
2. Electrical
❑Total Project Cost'(Item:6)x multiplier---_-- _---
3. Plumbing $ ^_. Other Fees: $
4. Mechanical (HVAC) $ 1 ist
5.Mechanical (Fire $ ---- --- - --- --- --
Su�pression) I Mal All Its -
/ Check No Check `mount Cash '1 tann
6. Total Project Cost: $ � $�.
�t ❑ Paid in f all J Outstanding Balance nee
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) S� 3 3 ..J /,•y,-t�p�s
_� GAY t S �O1rTr�/ License Number Expiration Date
Name of CSL Holder -
���� � List CSL"Type(sec below)
No.and Street TYpe Description -.
M ^ 6 �Q�� U Unrestricted(Buildings u to 3.).0o0 c.u. 11.1
�-(- / R Restricted 1&2 Family Dwellin
City/Town,Slate,ZIP M Masonry
RC___ Roofing Covering —j
-- WS Window and Siding _
/t SF Solid Fuel Burning Appliances
I Insulation
T---eleephoone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I (Ac- Hl Lion Number Ls�anon date
H'IC/Corr'pany N�,1rme or�1-IyLC RegisLar%.Name
I
City/Town,State,ZIP Telephone 1 _"
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure in p ov;,le •j; $
this affidavit will result in the denial of the Issuance of the building permit. -
i -
a..
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 author¢e
to act on my behalf, in all matters relative to work authorized by this building permit application. ""'0
fee a �Ir�e4ec�_ cov. r.r I - 7=le'l_3-----
- Print Owner's Name(Electronic Signature)
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION _ _I
a
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information j
contai in t is application is true and accurate to the best of my knowledge and understanding.
L -
I
Print Owner's or Authori' d Agent's Name(Electronic Signature)- - Date
"- NOTES: - .. --I.
1. 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 not have access to the arbitration -
program or guaranty fund under M.G.L. c.142A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.pov/di-
2. When substantial work is planned, provide the information below:
Total Floor area(sq. ft.) (including garage, finished basement/attics,decks or porch i _.
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" - -