27 1-2 CROWDIS ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR tiALGM
'? • RrrisrJ,I Lv loll
Building Permit Application To Construct, Repair, Renovate Or Denw kh a
One- or Two-Family Durllint;
This Section For Official Use Only
Building Permit Number: D e Applied:
Building Official(Print Name) Signature /Date
SECTION I:SITE INFORMATION
1.1 Property Address: t E
ors�Nlap& Parcil Numbers
�r)/a C�(& S�
I.la is this an accepted street?yes no er Parcel Number
1.3 Zoning Information: rty Dimensions:
Loning District Pn,poscJ Use RI Frontage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Reyuircd Provided Required Provided Reyuircd 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 s -stem ❑
Check if —M )
SECTION PROPERTY OWNERSHIP'
2.I wnert of RecordR (�
Vd (Xl�j i C.S
Name(Print) _ City.State,LIP
lS
19
o.and.treat Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ .Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
(Labor and Materials) y
I. Building $ I. Building Permit Fee: E Indicate how fee is determined:
2. Electrical S ❑Standard City,?own Application Fee
❑Total Project Cost'(Item 6)x multiplier _ x
i. Plumbing S ? Other Fres: S
J. \Iccltanical tll\':\(') S List:_ --
S. .Vechaniatl iFire
_ �— ---------
Su„rcssionl S Ftal All Fees: S_ - '------- -------- -
C'hcckNo. ('heck:\mount C;uh.\mount:
n. Total Project Cost: Y y1 n cry -- -----
"/� o _ ❑ Paid in Full 0 Outstanding BuLmce Due:
R � ,
SF.CI'ION 5: CONSTRUCTION SERVICES
5.1 (bnstruction Supervisor License(CSL) QQ /Y �U Gaa- i3
-F_/-%>�- --- ---
C License Numhcr Fcpiruion Date
Nantc o(l'SI. IIuIJcr
e List(-'St. f%Pc Isce below)
Description
No. and Street
hocstrieled I Ihtildin,s titi to 35.0110 cu. 11.1
It Restricted I l_' Famil Dtwllin
(:_tyi twat.. Lite.LIP M1I Nlasonry
RC Rooling C'overin
- A'S Window and Siding
�C SF Solid Fuel Burning Appliances
Insulation
'fete hone Entail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I gt/, 9
Cl �--Q� IIIC Registration Number Expiration Dale
IIIC o)f tpan Nantc or I fIC' Registrant Nunn
No;;A(r-s�
lO streetLimuil Jdress
Ci lJTown,State, VP rdc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of thi Issuance of the building permit.
Signed Affidavit Attached? Yes .......... 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 z:Zj` S\ — �'Oo a fZ S
to act on my behalf,in all matters relative to work authorized by this building permit application.
.�D � n o
lln ,,,t s Name(Liectrunic 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 application is true and accurate to the best of my knowledge and understanding.
Print Ossncr s nr:\uthuriicJ Agent's N;unc(lilcctnmic Signature) Dale
NOTES:
I. :1n Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program).will no 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
oust% to,n, ;os -,.I Information on the Construction Supervisor License can be found at o\%t k oas 1 on ,q±,
\Then substantial work is planned, provide the information below:
Total floor area(sq. It.) ____I including garage, finished basement'attics,decks or porch)
Gross living area l sq. It,I Habitable roost count
Number of fireplaces..___ ._ _. Number of bedrooms
Number of bathr oms Number of half haths
I)lie of heating sy stem Number of decks, porches
I — _
1'\pe 0fc00Iing s}stem . . _ _ 1`ndased _.Open
I, "I otal Project Square Footage'ntay he substituted tor-I'o(al Project Cost- 7- 30c) �A
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