7 CUSHING ST - BUILDING PERMIT APP i The Commonwealth of Massachusetts CITY
I� I OF
Board of Building Regulations and Standards SAL M
Massachusetts State Building Code, 780 CMR dMar
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Fa Dwelling
This S on For cial Use Only
Building Permit Nu er: ate Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Properly Address: 1.2 Assessors Map& Parcel Numbers
7 �vSf/iv� 57
Lla Is this an accepted street?yes 1/ no Map Number Parcel Number -
:, 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sqffii 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:
Public❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSIIIP'
2.1 Owner'of Record:
nETEK 0/97D
Name(Print) City,State,ZIP
7 e�Zlsstl vrr sr. 91k-d39 - VWSa
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction Existing Building❑ Owner-Occupied Erf Repairs(s) ❑.. Alteration(s) ❑ 1 Addition ❑
Demolition tf I Accessory Bldg.❑/J Number of Units Other ❑ Specify:
Brief Description of ProposedWork2: /rG�nO(/L� iQrD,�� 06JCK ^*' O 6i eLo5✓AC
.4a� rldv/LQ Sig% E
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ 3 1 , O U U 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ a 50 U ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ — 2. Other,Fees: $
4. Mechanical (14VAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3 31/U O 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
gkro 3 5, - / ct�d/3—
���� � License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
L7 'treett Type Description
Nod S — _
' - � U Unrestricted(Buildings u to 35,000 cu.ft.)
1 L _ d R Restricted 1&2 Family Dwelling
City,'3'an3isti'iie,ZIP - M Masonry
/'T
A , O/ pa? RC RoofingCovering
O WS Window and Siding
SF Solid Fuel Burning Appliances
aM60,4eM•401A 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
111 t7 $BNS !'ON% SiV C• HIC Registration Number Ekpiration Date
HIC Company a or HIC Registrant Name
No.and Street Email address
�,� • �/0/In/L7G.y ,/I/f' 97�-9yY-7Bau
City/Town,State,ZIP dry} Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........o-' No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize /;/ItVN$� .4U/ 7f So NS
to act on my behalf, in all matters relative to work aulasized by this building permit application.
r
PEl 6X ZN`6�ervl i X
Print Owner's Name(Electronic Signature) 13ate
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 Owner's or Authorized Agent's'afine(Electronic Signature) 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
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq:ft.) (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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"