10-12 CUSHING ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
y Board of Building Regulations and Standards CITY OF
O/ Massachusetts State Building Code,780 CMR Sd Mar� Revised Mar 2011
Building Permit Application To Construct, Repair,Reno r Demo 'sh a
One-or Two-Family Dwellin
This Section For Official Wse Only
Building Permit Number: lied: -
LV
Building Official(Print Name) natur -Date
SECTION 1: SITE IN O TION
1.1 Jo 7VM Pr i gs$: 'r-0 ` JT 0 0 T 1.2 Assessors Map& Parcel Numbers
1.1a Is rthiiss an accepted stree� no, ' Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: ,
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(it)
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❑
y� � �r �_ SECTION 2: PROPERTY OWNERSHIP' rn y� Q 2.,�,7�dNordlC t V( 1 �l II1� 'lU / l I 1 1 T! Q/9U
Name(Print) I ' City,State,ZIP I
l9 C a,� nn /o ham brl (I 9 J : g o2lb �
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Descripti of Proposed orkz:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 'V-_) 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑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: $ 7W, ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 5 /-733 2 1 5
� r i s h �:� z,(a
License Number ExpuatiLonD e
Name of CSL Holderl
11 G W T ,(,�`I'+ ) (S f List CSL Type(see below)
No.and Street ^ Type Description
JLM U Unrestricted2 Family
(Buildings u el ing cu.ft.)
" ' I� 1 1 1.1 R Restricted 1&2 Famil Dwelling
City/Town,State,Z4P M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
(g O C I insulation
Tele hone mail address D Demolition
5.2 gegistered Home Improvement Contractor(HIC) O 0 / Z 6 �,2
G HIC Registration Number tP xpvatio Date
HI (torn e o C Re ' r nt Nrame
an SVe 1 /1J1 LI�IIJ 1.1 cis ff V 1
-,�7�I�oy2,� P�� Emailaddress
Ci /Town, Stag,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. § 25C(6))
Workers Compensation Insurance affidavit must b completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan a of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
APPLIES FOR BUILDING PERMIT c�" I I,as Owner of the subject property,hereby authorize r f S l I/ s/r Za 7— LJ
to act on my behalf,in all matte,(s relative to work authorized by this building permit application.
Susan
Print Owner's Name(Electronic 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.
ri5h 0K DU
Print Owner's or Auth rized Agent's Name(Electrons ignature) 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
wwtiv mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.zov/dps
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"