52 CROWDIS ST - BUILDING PERMIT APP 22.
The Commonwealth of Massachusetts ARE, V
s Board of Building Regulations and Standards r fALENi'
Massachusetts State Building Code, 780 CMR
7 evised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish`�d� �Oy —3 P 12 q
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
IJ
f �•x1� ll 3 I1•
f Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Proper doss: n• 5—`S0s — 1.2 Assessors Map& Parcel Numbers
K
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
t j 1.3 Zoning Information: 1.4 Property Dimensions:
VY-- Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required 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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qrw�F'of ecyr �
1,�.1t�11
Name Pont //^^��++ ^^ City,State.ZIP
No.and Street - Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Propose Work':
rGA
SECTION 4: ESTIMATED CONSTRUCTLQNjgOSTS 1-76
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ I. Building Permit Fee: $ -IAdicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression) Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
11 Mgt o CEDiP,cz S
SECTION 5: CONSTRUCTION SERVICES
5.1 COBstrnction Supervisor License(CSL)
1M, /9 ti License Number Expi fl to
(Print)Namc of CSL older
^ t' 1cln, List CSL Type(see below) Id
No.and Sit t Tme Description
�y U Unrestricted(Buildings u to 35,000 cu.ft.)
City/Town, ZIP/124 R Restricted 1&2 Famil Dwelling
M MasO
Aw�34 2 1 RC Roofing Covering
Cell# Telephone# WS Window and Siding
SF Sohd Fuel Bruning Appliances
I J Insulation
Construction Supervisor Si ture D Demolition
5.2 .Registered Ho Improvement Contractor(HIC)
1 U/�
HIC Registratio bar ra. Date
(Print) C om Brae r HIC Registrant Name
No.and Sir -
l �, � ��� HIC Holders Signature
City/Town, State, Telephone
SECTION
Email address
6:WOREERS'COMPENSATION INSURANCE AFFIDAVrr(M.G.L.a 152.§25C(�)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to
provide this affidavit will result in the denial of>lssuance of the banding permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERbnT
I,as Owner of the subject property,hereby authorize(print name)___ �pl(,)n�t� to
act on my behalf,in all matters relative to work authorized by this building perm�ft application.
Print Owner's Name ! Signature am
SECTION 7b:OWNER OR AUTHORIZED AGENT DECLARATION OR CSL HOLDER
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this app is true ac at the best of my knowledge and understanding.
Il`
Sigr66eSof wnei's or Agent's!CSL Holder Name Date
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 not have access to the arbitration
progam or guaranty fund under M-G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.sov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
In accordance with M.G.Lc. 40 §54A. A condition of this permit is that all debris resulting from this work shall be
disposed of in a licensed waste facility as defined by M.G.L.111 §150A. *Dumpster on site OR removed off
site *Dumpster Co.Name .Address