37 DANIELS ST - BUILDING PERMIT APP 1 B_
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The Commonwealth of Massachusetts
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Board of Building Regulations and Standards CKCEIVE
Massachusetts State Building Code,780 CMR,7a'edition NSFIMMAL SERVICES
Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1.2
One-or Two-Family Dwelling 1014 AYH1 8 2 U
This Section For Official Use 9nly.
Building PennitNum
Signature: +v
.Building Commissioner/In ector of Buildings Date - -
SECT101Y 1 ;sITE;INFORMATION
1.1 Property Address: 1-1 Assessors Map&Parcel Numbers
1.1a 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 if yes❑ Municipal❑-On site disposal system ❑
-SECTION;;:_,,04tOPE14w OWNERSHW
2.1 o�ner gf Reco d:
/''arch .-e �SZ C_ Z I-, 3� a /'e S _
Name(Print) Address for Service:
Signature Telephoneor �
SECTT - -
ION 3:`DESCRIPTION'OF PROPOSED'WORK (check all that apply)
n
New Construction❑ rExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units - Other ❑ Specify:
Brief Description ofProposed Work 2: o �;
c o
SECTION 4:ESTIMATED'CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials , • `Official Use Only
1.Building $ z1 Building Permit Indicate how fee is determined:
2.Electrical $ Statidazd' City/Town;Application Fee
❑Total Project Cost',(Item 6)x multiplier x
3.Plumbing $ '2 OtherFes
4.Mechanical (HVAC) $ =List &?
5.Mechanical (Fire
Suppression $ Total All Fees $
Check No:.. Check Amount: Cash Amount:
6.Total Project Cost: $ p Paid in Full ❑Outstanding Balance Due:
M At L fU 0 N► r N F1 IJ
SEVz �` sit
SECTION 5 ,;CONSTRUCTION,SERVICES-
5.1 .Licensed Construction Supervisor(CSL)
6 aV�jJ,',9Y Tt o`t
C 3:3'V'93 1 J 1 VM(X:r�& i? L License Number Expiration Date
Name of CSL-Holder 1 �1 List CSL Type(see below) V
7 . , ; .Description
Address ,�, U Unrestricted u to 35,000 Cu.Ft.
AST dZ, `"'"`"�" R Restricted 1&2 FamilyDwelling
Signature M Mas my Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re 'stet HgQte I provement Contract� IC) /
HIC Co�ypan Name or 111C Reg14 t me Registration Number
Address 'nQ -� J-', "�Ty
7k_741J—k 30 Expiration Date
Signature / Telephone
SECTION 6:WORCCERS'COMPENSALION.INSpReANCE 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 .......... No...........❑ -
SECTION 7a:OWNER A.UTHORIZATION,.TO,BE C0111PLETED VlHEN
OWNER'S AGENT//OR CONTRACTOR APP,.LIES`FOR BUILDING`-PERMIT ,
67 as Owner of the subject property hereby
authorize G �� , c to act on my behalf,in all matters
relative to work authorized by=pelacation.
/ L
Si nature of Owner Date
SECT[ON.7b2 OWNER'OR AU I HORIZED AGENT,DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf
Sl
Print Name '
/19A �a z-r-, d � �
Signature of Owner or Authorized Agept' Date
(Signed under the pains and en'a *es of a '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 110.116 and 110.R5,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"