19 CUSHING ST - BUILDING PERMIT APP (002) SJ The Commonwealth of Massachuscits Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7"edition logmlkvw
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lding Dept
Building Pennil Application To Construct, Repair, Renovate Or Demo
(� One- or Tiro-Fomilp Duelling
v _ This Section For OfTtcial Use Only
Building Permit N r: Date Applied: a
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro�Rrty Address: 1.2 Assessors Map& Parcel Numbers
i9 C y 5'li!r2A
1.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(It)
13 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c. 40.I54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if esO P pO y
SECTION 2:
PROPERTY OWNERSHIP'
2.1 Oft t'A-5Lx- PE
Sf
Name(Print) Address for Service:
i l _ C - �: (�P71 ' 5-2q - '5 !rF7
Signature (] Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
B 'ef Description of Proposed Work': 5-1 6- Vf
ty tow 4! a.L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materiab
1. Building s 3— o0o I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing $ 2. Other Fees: $ jy�j T
4. Mechanical (HVAC) S List: "�-( ( )
5 Mechanical (Fire S
Su ression Total All Fees: S
Check No. _Check Amount: Cash Amounl:
v 6. Total Project Cost: f q,066.
7�• OtS ❑ Paid in Full 0 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
" - License Number Expiration Date
N;poe of CSL- liplder List CSL Type(xe below)
Tvpc Description
Address
U Unrestricted u to 15,000 Ca Ft.)
R Restricted IR2 Family Dwelling
Signature M Masonry Only
RC Residcntial Ron Covering
Tclephone VS
Restdenual ofi
Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
S.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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........... O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
Jauthorize to act on my behalf,in all matters
ative o work authorized by this building permit application.
nature of Owner - Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si ned under the pains and penalties ofperjury)
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 3[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 I I0.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halfibaths
Tvpe of hearing system Number of decks/ porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage"may he substituted for 'Total Project Cost"