6 DEARBORN ST - BUILDING PERMIT APP The Conuttonwealth of MasSUChLISCUS
t Board of Building Re ulatiuns and Standards
t . f %Iassacliusctts State BUildiml Code. 780 CMR. 7"' edition I'.Sid
\ Building PCI"halt Application To Construct, Repair. Renovate Or Dcntuli;h a Rrrn
One- ur Ttru-F I DrrHhIL, 'un,4
This S tion Fur Official Use Only
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Buildimt Permit Number: Applied:
Siena(ure: ;.!/,r.J'/�✓J Cj /O OX ---------
Building Cum mi ss uuer/ it spertor it Balldl s Dale
SEC ' O : SITE INFORMATION
1.1 Pr erty address: SfYP�� 1.2 :�ssessors Nlap & Parcel Numbers
1ionr
, rbon f ----
1.I a Is this an Ucceptrd street? yes, -Z— no Map Number Panel Number
— -
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District_ Proposed Use Lot Area(sq 11) Frontage iIt)
1.5 Building Setbacks(ft)
Front Yard Side Yards - Rear Yard
Required Provided Required Provided Required Pro<[dud
L6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public ❑ Private❑ Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
MOwners of Record: ci-A9� /7l-A n, � Y
nte.l AID X Lo Dearbor � PP �
Name-(Print) Address for Service:
X P 6 � o� ((t-7$)
�Signature —��—
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) Ed Addition ❑
Demolition ❑ Accessory.Bldg. ❑ Number of Units—r2,,,_ I Other ❑ Specily:
Brief Description of Proposed Work-:
-pincee r I � n YY
Sav� IC ))+h nPa nQre t T Fir( r,t iv� tr of
I I n
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Casts: Official Use Only
Item (Labor and Materials)
I. Building I. Building Permit Fee: $ Indicate how fee is deternuned:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa (Item 6) x multiplier x
i
3. Plumbing $ '. Other Fees: $
a. Mechanical (HVAC) $ List: —
5. Mechanical (Fire S 'total All Fees: S — —
Su ression)
Check No Check :\muunr ('ash :\nnxun:_--_-
.. j b. rotal Project Cost: '� ��-a JA ❑ Paid in Full O Outst:mding I3al:mce.Uue:___
i
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSI_) 5 J 733 f/l�fa)D-5
r LccnSe Numhcr 1:xpiifr'':uiwl 1%10
N911C of C'SL- I lulder 1_tet C'Sl_ f%pe (see helaw)
Tv e Dcsc1 1 10011 .
\ddress /�I L Llv'estndeJ rt!, to??.(1O0 Cu. 12 1
R Restarted l&'_ Famllt D„rllins
Signatt!', /� \1 \laumr\ Only
V '"J RC Residential Rooting Cotenn•�
relephol,c \vs Re,idcnuul \ ndkm .1 SiJinc
SF 12csiJeini;d SohJ Fuel Bunting \,th aorr In,t.ilLwnu
D Re,ldcuual Demolmon
5.� Rel; tered ilome Improvement Contractor (HIC) lC)l LOCK _—
reT 52J'V LLDSy =hC- Registration Number ..
I11C Company. Na�e or MC R,glstrant Name
AJdr s: I o
(q�8>7H I -Dllo�� Expiration Date
Signal e Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
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, n t as Owner of the subject property hereby
authorize r�J _ Y7�['� Z� to act on my behalf. in all matters
relative to work authorized by this build g permit application.
x V
Si mature of Owner Date
SECTION 7b: OWNER( OR AUTHORIZED AGENT DECLARATION
I, C—hr—I e..laDp 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.
=Nw-.
rZ
Prin /
Signature ol'O, ner or Au orized Agent _ - Date
(Signed under the 2ains and penalties of er'u ) -
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. Ia'_A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be fi,tmd in 780 C NIR Regulations 1 10.116 and 110.115. respectively
?. When substantial work is planned, provide the intormation below:
Total flours area (Sq. Ft.) (including garage, finished basemenUatties, decks or porch!
1 Gross living area lSq. Ft.) Habitable room count -
Number of fireplaces - Number of bedrooms --_
Nu,nber of bathrooms Number of halt/h:uhs
Number of decks/ porches
- - fvpe of healing syuem _
_ type �>icooling system � --- -:..
Enclosed -_Upc❑ _ ...
3. "Total Project Square Footage• may be substituted for 'Total project Cost-