6 DEARBORN ST - BUILDING PRMIT APP 2 t.
�\ The Conunomcealth of Massachusetts R
t 13oaid of 13tulding RCM11LI60111S and Standards
MaSSaC11LISCItS State 111ildino Code, 780 CN1R. 7 ' edition I'.SF
l3uildin_ Permit Application To Construct. Repair. Renox:de Or Demolish a
One- orTvo-FamilyDtrr(ling, _un8 i
r� i
V\ This Section For Official Use Only
Building Permit Number: Date Applied:
si�,,natute: "�y �
Building Comnussioner/ Inspector of BmlJiugs Dat—`-- -t
1 l
SECTION 1: SITE INFORMATION
1.1 Pry) :address: 1.2 Assessors Map & Parcel Numbers
aarborn �tre�t - -
1.la is this an accepted street? yes ✓ no blaP Number Wu.el Numher
_
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage ut) -
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
! Required Provided Required Provided Required Prodded
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[
�tIt Owner[of Rec rd:
i>G1 _l/ar-e___ Alex Lv Dearborn ]xee +
Nato ino D(�6rjEL ALEX 4A9 Addressfor Service:
X "D QL aabLl �e� t97S)7115 - 3J-ISO
nature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied � Repairs(s) ElAlteration(s) M,- Addition ❑
Demolition ❑ Accessory.Bldg. ❑ 1 Number of Units Other ❑ Specil'y:-
Brief Description of Proposed Work'': _ 1 I r�.l.l.)
1 I
I. v
J of
SECTION 4: ESTIMATED CONSTRUCTION COSTS
(25
W
stimated Costs: Official Use Only
(Labur:md Materials)ng $aa L Building Permit Fee: $ Indicate how fee is determined:
❑ Sumdard City/Town Application Fee
ical $ +❑ Total Project Cost- (Itzm 6) x m Itiplier sing $ 2. Other Fees:nical t HY':1C) $ List:nical (Fireion) Total All Fees:Chick No. Chzrk :\mount: <'ash :\n mtProjectCost:_. .X 'aJ�
❑ Paid in Full ❑ Outstandine- I3ul;mce.Uue:_
I
/ tylvo t)
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) F-7
_fie I, �,�.�,-_t„ �L.iccnsc \—iunhct I[vpi r://ui�//ru l :ua
Nante of CCL�SLSL 1Iol lee Lot C'SL'I'cpe )see heluwl mod---
1L�T._1�Llly l\ e Dcseri num
\J11re.,f, - _ ( 1. ItfCSln l'IC��111 to 1 )00 Cu. FI
-- - R Restricted I&'_ F:uwh [mOmnv
.tilenatu � \1 kLhonn 1 R
ry
KC Rdemi1ou0ne(•Men ng
Telephone \\'S Residential \Vuldoo .wd ."iJme
5I_ &ntial Solid fuel Bum." \ tluwre lus),J Lw��u
D Residential Deinulmon
5A Rego tered ilome Improvement Contractor (111C) l01[o09 __
SP1 V�DS Y1 Re_isuatiun Number
li IC Cunipany
res Nance or li R• scant Name
5alzirn !�%a�Jio
,add - - - - - - - 19�R17�I-DLIo��J
Fxpvuuon Date
Signature
Tel�ne
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 pots ide
this affidavit will result in the denial of the Issuance of the building permit.
." Signed Affidavit Attached? - Yes .'E7"—' -._-No -..�..... p._ - . - - -
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, bariyi Dr Cf' nr - Al c - -. as Owner of the subject property hereby
authorize rja=VJ er Zr (>iiation. to act on my behalf, in all matters
relative to work authorized by this building permit applic
X J
Signature u Qll ,F Date
l
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Jr Z�rZ A , 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 knuwledee and
behalf.
Print
Signature o Os er or Autho ized .,,gent Date
(Signed under the gins and eZhies of er tl ') -
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered cuntnwtur
(nut re,istered in the Home Improvement Contractor(HIC) Program), will not have access to the arbilranun
program or guaranty fund under M.G.L. c. 142A. Other important infor mation on the HIC Program :md
Construction Supervisor Licensing (CSL) can be found in 780 C•MR Regulations I IO.R6 and I IO.RS. iespeairely.
' When substantial work is planned, provide the information below:
Total flours area lSq. Ft.) (including garage, finished hasement/atncs, decks or poichi
I Gross livm_e area ISq. Ft.) Habitable room count --
Number of hieplaces Number of bedrooms ----—
Number of bathrooms Number of halt/hwh;
fvpe of heating systern Number of decks/ perches —_----
Type-�tFcoulin�� s)'stem_ - _ .. . Enclosed _ (.)pen.
. 3 ..Total Project Square Fuolage•' may.be substituted fur "Total Project Cost' _�