15 CUSHING ST - BUILDING JACKET The Commonwealth of Massachusetts
` Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7t° edition IQ) R 0 sr ed aJQ� n ary
Building Permit Application To Construct, Rep ' , R novate Or Demolish a 1, 2008
One- or Two-Family elfin
This Section Fo fficial Ilse Only
dr Building.Permit Number: DateA ied
Signature: 7�Utt�
it ingCommis oner s ectorof mg Date
SECTION 1: Sift INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
Is c 7�. 4-r3- al.I a is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check ifyesD Municipal ❑ On site disposal system D
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
ISr0 G, IIPsr�� � t5 L' ysh � r,o, S+
Name(wi 11, Address for Service: /�
7 - 7C q- 73ci cl
S tore �— /V Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition D Accessory Bldg. ❑ Number of units_ I Other ❑ Specify:
Brief Description of Proposed Work : t- 6 ,mom eg- 1-2p h , :) , I eo
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ D Standard City/Town Application Fee
❑Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ 11_�
4. Mechanical (HVAC) $ List: '�l�Q
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ a -I 06 . CCU ❑ Paid in Full 0 Outstanding Balance Due:
♦ SECTION 5: CONSTRUCTION SERVICES
5`.I Licensed Construction Supervisor(CSL)
R3rd I S Z- I 3 - 13
�zrV, � (s 1 License Number Expiration Date
Name of CSL-Holder
eIh List CSL Type(see below)
Addres Type Description
U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwellin
Si ature M Mason Only
8" L4 N — 1 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improveme t Contractor(HIC) f �I Z,-Tn. µ a.1 -la Ica
H}C Company`Name or HIC Rngist Nam—e � Registration Number
_S2 � 6,c fCY an-. 4 - 2� - 13
44 Addr s
-39-744 _ 1 }+ Expiration Date
Si ature 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 ..........`d No ...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorizet=m to act on my behalf, in all matters
relative to xwrk authorized by his wilding permit application.
• Si ture Owner at
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
I,_ as Owner or Authorized Agent hereby declare
that the statements and information on a foregoing application are true and accurate,to the best of my knowledge and
behalf.
h e T�
Pnn e
1:2
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of u )
NOTES:
I. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementiattics,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"