11 DALTON PKWY - BUILDING PERMIT APP The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7h edition MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January
One-or Two-Family Dwelling 1,2008
,,�This Secti6fifof
Building Permit Numg�e • b Date Applied; v 1-51% 0!71:
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Buildin
g issioner/Inspector pfBuildings �Ditt,
wSECTiON l-'SITE
1.1 Property Address:
0,ltee wI 1.2 Assessors Map Parcel Numbers
1.la Is this an accepted street?yes L/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(11)
1.5 Building Setbacks(11)
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[I Private 0 Zone: Outside Flood Zone? Municipal C3 On site disposal
Check if yesO system 0
SECTION 2: PROPERTY OWNERSHIP,'
2f�FNf Record:
Aw // /a 7d/v
Name(Print) Address for Service:
97s-- ?Rl- V44
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) ,,
Alteration(s) 13 Addition 11 1
New Construction I� Existing Building 0 Owner-Occupied 0 Repairs(s) E3
Demolition 13 Accessory Bldg.C3 Number of Units Other 2"Specify:
Brief Description of Proposed Work2: VIALy L 51&Alh
4sr mv,14, SECTION 4:ESTIMATED CONSTRUCTION COSTS:'
Estimated Costs:
Item (Labor and Materials)
4 Official Use Duly
1.Building $ 00(j -V.,Building Permit Fee., Indicate how fee is determined:
0 Standard City/Town Application Pee" V4
2.Electrical $ 500 ,OTotal Project Cost'(Item 6)x multiplier, X-
3.Plumbing $ 2. Other Fees: $4,,
4.Mechanical (HVAC) $ List, !c",
5.Mechanical (Fire
$
Suppression) Total All Fees!$
6.Total Project Cost: 00
Check No s Check Amount: Lash Amount.
P Paid in Full 0 Outstanding Balance Due:
SECTION Ss CONSTRjCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
/J,-- License Number xp1ration Date
Name of CSL-Holder
:7D a lu if D Sir //AM�L�aJ List CSL Type see below)
Address„ /rl/P' ,al:. ,a': < •"sn., .^`� + I escri�tion nip,
U Unrestricted(up to 35,000 CU.Ft.
Restricted 1&2 Family Dwelling
S' ature V Masonry Only
M-Zyy-70070 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
a SECTION 6:W O IN , w • F _W v: �
ORICERS'� INS
URANCE SURANCNC E 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..........9?" No...........❑
SECTION 7a:OWNER'AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMITS
I, as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER'ORAUTHORIZED AGENT DECLARATION ..
I, 4e.f"m zll e- ,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 � 7/.Sd/6/
Signatup o£Owner or AuthorizM Agent Date T
(Signed under the pains and allies of
n ,«a,� -r,ome,.. •r 4:a ne ,.fir.n , " NOTE3.
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,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 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"