3 DEARBORN ST - BUILDING PERMIT APP (002) (� The Commonwealth of Massachusetts
�- Board of Building Regulations and Standards CITY
O
U ���41 Massachusetts State Building Code, 780 CMR Rerised A/or 2lll/
L 111
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-o Tivo-FantilvDiveling
Yfiis Section For Official Use Only
Buildi ig P it Not r: Date Applied: r
13ui1 ng Of cial(Print Num Signature ��T Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
3 b�R1�R1�1 SCl2��'S• -
I.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 It) Frontage(It)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes[] Municipal❑ On site disposal system, ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
/A'r= LLSE = M M a 19 ZD
Nmne(Print) City,State,ZIP
No. an Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building 9/ Owner-Occupied id I Repairs(s) ❑ I Alteration(s) ❑ 1 Addition Pj
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': -N,.�SJ Q t7FLIL.
SECTION 4: ESTIMATED CONTT UCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City own Application Fee
2. Electrical S
❑Total Project st (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S
Su ression) Total All Fees:$
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S �za(jO d 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Eapimtion Date
Name of CSL. I folder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted Tuildinas no to 35,000 cu. ft.)
R Restricted 1&2Fatnil Dwelling
City/town,State,ZIP M Masonry
RC Roindow and
Siding
ofin Coverin
RC
W
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) '
=Reg.,1,jtionr%pirmion Dale
I IIC Company Name or I IIC Registrant Name
No.and Street
ss
city/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE 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 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 on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
cont^ained,,in this application is true an curate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Nante(Flccuonic Signature) - pate
NOTES:
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 root have access to the arbitration
program or guaranty fund under M.G.L. c. 1.12A.Other important information on the HIC Program can be found at
yww.nriss.�- )v oct Information on the Construction Supervisor License can be found at wit w.nmsagov 4lps
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) 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 _ Linclosed_ Open _-
3. -Total Project Square Footage"may be substituted for-Total Project Cost"