16 DANIELS ST - BUILDING PERMIT APP q_z2 .2509: .
The Commonwealth of Massachusetts I
RECE ED
Board of Building Regulations and Standards '
Cy ITY
Massachusetts State Building Code,780 CMR,7's edit PEC?ION g USE
Building Permit Application To Construct,Repair,Renovate Or�
� ;� ;IZAis�l41c6y"
One-or Two-Family Dwelling �p�1(� 1,2008
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature "
Building Commissiorier/InspectorofBuildmgs . Dare`
SECTIONS:SITE INFORMATION
1.1 Property ddress: 1.2 Assessors Map&Itnrtlel+Nnmlkrs + "
L la Is this an accepted street?yes_ no Map Number "- .` .P cel Number
"at1.3 Zoning lnformationc .,; •c" ,tr' 1A Property Dimensions:f • "
Zoning District • - Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
-• "" FrontYard' Side Yards RearYard
Required" ,• Provided - Requred 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 yesO
,. SECTION-2:PROPERTY OWNERSHIP' ti
2.1 Aiynerl of Record:
/G �anre-lS ,
Name(PO).) Address for Service:
Signature - Telephone- -
-SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check'aB that apply) - ``
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify:
Brief Descriptiony�'Proposed World:
V/' = . g P - b =1
vow
SECTION 4:ESTIMATED CONSTRUCTION COSTS V
.. . Estimated Costs:
Item . Official Use,Only. ,
Labor and Materials
I.Building"' $'o23Z 5% ..•�•. 1. Building Permit Fee $ Indieate how feels determined:
2.Electrical $ q Standard City/ own Application Fee
0 Total Project Cosy.(Item 6)x multiplier
3.Plumbing $ 2. Other Fees: $ '.t •"`
'
4.Mechanical (I-IVAC) List-.
$ � -
5.Mechanical (Five
Suppression) $ Total All Fees:$ ;
Check No. Check Amount:" Cash Amount:
6.Total Project Cost: ❑Paid"in Full ❑Outstanding Balance Due
.-o c ot�1TRAc� pc� b� l�
i
p
SECTIONS:•CONSTRUCTIONSERVICES
5.1 Licensed Con �� h• i Supervisor(CSL)
License Number . Expiration DaleMF
-
Nameof.CSL-Holder - • (J�
.3 •.r 3�Fhltcln�$h'Cr>t List CSL Type(see below)
Address Salean MA @;qf Q .':�', ;.:De§ai-`lion"
U .Unrestricted u to 35,000 Co.Ft
Signature R Restricted 1&2 Family Dwelling
. M .Maso Only _
RC Residential Roo2ng Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Gene Installation
y D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) y
Atlantic Weathaization_ I J C "
HIC Company Name$r Regis lion Number
Address MA 019'" 3 �
Expiration Date -
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFH/AVIT o.G,L.a i52.:§ 25C(ti))
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 oEthe building permit.
Signed Affidavit Attached? Yes.......... No.
SECTION 7a O,WNERAUTHORIZi1ATION•TO:BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR WELDING PERMIT.
I,- IS4 )-e� Pot r l a fv as Owner of the subject property hereby
authorize T[r t �A (w to act on my behalf,in all matters
relative to work authorized by this building permit kvn, gaapplication.
AL, /its�iy
Signature of owner Date -
SECDTIOIN 7b: 1;AUTHORIZED OWNERr7O AGENT DECLARATION ,,-•
t q/I, 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.
E(, L P
Print Name � - - •
Signature of Owner or Authorized Agent Date
(Signed under the vains and penalties of -
NOTE&
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 I10.R6 and l I0.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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"