9 CYPRESS ST - BUILDING PERMIT APP it
r — _ I311J I'dt,,.l I3111IJ I11�\IlCLI'fIId11lA1s,111dI Stend,,i ------- ---- -- -- - _.._ .
. • d, I t Ilt
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l y \lj s.nhL r Its State 13uildim! Code. 'SO ('MR. t' rdmon
Building I ennu Application ru Cununln. Re Ju'. Ite•mtt,ur Ur Ih•nnili,h a i R� ,��• ,/ /.„i,,,,, ,
Otic- nr �,ut-Piutulr lhirlhnV' ! "'i
Sernnn For Offmal l',e Only --- ---- --- .
Date Applied
e
liw lJinp Cmu : n. -.uir of Budding, Daic
—_ SECT ION, 1: SITE INF(3R\IA HOti -
1.1 Property \ddress: 1.2 \sseasurs \Eup & Parcel ',umbers
X QI---e-YPREss -<;r- --- _ .
1 la Is this In a,,epted ,n«1 sec _ __ ",'I, � \I ip\uwM•r I'u.J \r,oih.i
1.3 Zon.ng inferntat. n7;
i
,, I s• imz Dnl nrf P',;w�cJ I >r I Li 1 \L.. ',y Ile `"•!I :
I LS !Building Setbacks Uq __----
. Fnmi Yard Side Y.uds 6rur 1 a:d i
Reywird _ Pru,idcd e twed I`n r.;Jed Ra un rd Pi J.J j
E.F. !rater Supply: i.vt G L e. 4U. §.511 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone:' I
• — •Munlcl al ❑ On Site duuxJ1 N"•1CM ❑
, Pm ale❑ P I
Pw u,. ❑ Check it yes❑ _
1.
SECTION _. PROPERTY OWNERS►IIP
S C
X 2.1 Oe'nerl of Record:
. P_AB 0 2 LDRR — _ 9 cRize5s
N. ' i1'nnli Addres, to,Sei'�iee'.
9-7S- -74j'3` '8
irc , ore Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK z (check all that appfv) _
New Cunstruc[iim ❑ Seating Bwldin , ❑ O\,ner �-u O pied xQ Rep:ursf:.1 ❑ I \L..rauum,i ❑ 1._\,Jdi,im ❑�
—
Drmiliitian ❑ .Ar'_essoiy Bldg- ❑ Nolnbr; of Units:: _— Other ❑ STeu iy
xFFil< t ipin:h : Prup<,sed \V:.;h .__ .—
' - - - • I�C�LAcE . _F. 8�I'T.._.fWdcs-!- E'ER �'
SECTION d: F.STI\IATED CONSTRL'CTFOiV COSTS
Item Estimated Costs: Official Use Only
i Lahnr.ind Materials)
I I3uIIJn,g —� I I. Building Permit Fee: 'S_ Indicate hi,%% lee dewt uunrd:
--Z .-
Standard City'/Town Applicau,at Fee
'_ Flectnral 5 ❑ r (al Project Coat' (Item 6) s multiplier
3 11Iunhin¢ 5 �. Other Fees: 5
1 1lrrham li\'
ral i :\CI 5 --y I.i's
i �h�hJnrc.11 (Fire --.. _ .....
( heekNn _ l�he�k .\nlnuN' l'.nh \ni,wnt
Xb total Project Cull I 2t S(N ❑ Rod in Full ___ ❑,(,hn_A.ulJing 13.0.in.e Uur_ _
SECTION 5: CONSTRUC riON SERVICES
5.1 Licensed C'onslruction Supervisor (C'Sl.l ,
Li.cnse Number I)ali.
('SI. If der
l I nirsu i.orJ upw �s oMNl(L 1�1 ' ___—_ __—
.___—__. Resui cd A.
iignalnle \I \lasonrn thth
1'.1 phani \\S }Ki,iJ,nU,,l \\ n,lm, o J
sl Ra�iJ;in i.Il Ld;J I wl If Iu u`\Lll In lu�i I I m
5.2 Registered Home Improvement Contractor (111C•) - —
HIC C•ougtms .Name or IIIC Registrant Name _.— _—_ Kiglsnauun Nuulher j .
— Frpnawrct Date
Signature felcpinme
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT(N1•G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. F.Idurc o, pnlwJe
this affidavit will result in the denial of the Issuance of the budding permit.
Signed Affidavit Attached" Yes .......... ❑ 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 to act tin my behalf.In all m:uiers
:'elative to w,nk authorized by this building permit application,
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 . as Owner or Authorized Agent hereby Jeclate
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. - -
Print Namc -
Signature ul Owner ur AuthunnJ :\gent Date
Si meJ unJer tlti alnsanJ enalues ul rL o
NOTES: _ {
I. An Owner who ubtams a budding permit Io do his/her own work, or an owner who hires .,it unte�_Istcled .,mtra, 101 -I
(not registered In the Home Improvement Gmtractor (HIC ) Pr(...ram), will not have access to me .uhitration j
program or guaranty fund under M.G.L, c. 142A. Other important informaton on the MC Pri,Lpram :Ind
Construction Supervisor Licensing WSLI can he found on 780 CNIR Regulations 110 R6 .mJ 110 R5. respeallvck
' When suhstamial work is planned, provide the mhltmation below:
Vaal Ilmas area ISy. l'1J uncluding garage. finished hasenten Ua(tocs. decks t;r p,irch;
Gross loving area I}y. Ft.I Hahnahle mint cnunt
I Number of litrplaecs_ Numhet nl hcdnnams
`umber of h.uhol,aus - - - - Nanther Of
I\pr �J heating syslem __---_ N'umher,;f Jcak,i p,a.hes
Iv I le ��t .,�,din g s\slctn _
7. `h,aal Pn,lert SLIuare F,wl.lge'• may he substituted t,,r "5,ial Project
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