35 CROWDIS ST - BUILDING PERMIT APP 3-7 5" j2`�
i "rhe Commonwealth of Massachusett¢SPEC71019AL $ER ICE
OF
Board of Building Regulations and Standards AL M
a 780 C SALEhI
0 � Massachusetts State Building Code, NA MAR � 5 A 4&ed,yhrr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
v - nmillin
^^nn One-or Ts ly Drve a F g
IV 1
This Section For-Official Use Only , -
N ll g Budin Permit Number: Date Applied:
I 3 is IC.
Building OlTlcud(Print Name). Signature•: '_ - Date
SECTION It SITE INFOR�INIATION
n(� 1.1 Property Address: 7 1.2 Assessors Map Sr Parcel Numbers
1.I a Is this an acce led street?yes_ no M1fap Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) - Frontage(It)
1.5 Building Setbacks(R) .
Front Yard Side Yanis Rear Yard -.
Regaind Provided Required - Provided. Requited Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
if ca MuniMunicipalO On site disposal system O
Public O Private O Check D - -
SECTIONZ: PROPERTY OWNERS11
2.1 wnert of R ard: ��zy 11rA �Y7
tome(Print) City,Slate,ZIP
35- G.2v; v,?. der ��J�'744 7wzr
No.and Stmet- Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction 0 Existing Building O Owner-Occupied O Repairs(s) Alterations) O Addition O
Demolition O AccessoryBldg.O Number of Units Other O Specify:
BriSW esc . tion of Proposed Work-: -
CTION a:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityfrgwn Application Fee
2. Electrical S ❑Total Project Costs(item 6)x multiplier x
J. Plumbing S 2�Qther Fees: S rJI y� x
4.1%lechanical (tIVAC) S List: O/nU (/
5. \lechanicel (Fire S Total All Fees:S
Sup ression)
Check No._Check rlmount: Cash Amount:
6.Total Project Cost: S Jf� , .$�d J ❑Paid in Full ❑Outstanding Balance Due:
rnra►r
•F'.+f i."R^=SECTION S: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ,
License Number Expiration Date
Name of CSL[folder List CSL'rype(see below)
Type - ` ': Description .
No. .md Street
U Unrestricted(Buildings no to 35.000 cu. 1t.
R Restricted M2 Family Dwelling_
Cilyrrown,State,ZIP M Masonry
RC Roaring Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Tcle hone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or[IIC Registrant Name
No.and Street - Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§2$C(6)p;
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the isivance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7o:OWNER AUTHORIZATION,TO BE.COMPLETED.WHEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
u contain in t/vhiiss'(application i rid accurate to the best of my knowledge and understanding.
\ Print Owner's ur/\`uhoriz gent's N e(Elecuonic Signature) Dale
NOTES:
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 LLgi have access to the arbitration
program or guaranty fund under M.G.L.c. I J2A.Other tat orant m-format)on on the HIC-Pro gram can be forth
www max,eov:'oea Information on the Construction Supervisor License can be found at www.mas�
2. When substantial work is planned,provide the information below:
"rota) floor area(sq. R.) N (including garage,finished basement/attics,decks or porch)
Gross living area(sq. Il.) 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 ofcoolingsystem Enclosed Open
3. 'Total Project Square Footage"may be substituted tat"Total Project Cost"