15 DEARBORN ST - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards
O Massachusetts State Building Code,780 CMR, 7° edition MUNIL lSE ITY
1 Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January
One-or Two-Family Dwelling 1, 2008
This Section For Official Use Only
`��� Building Permit Number. Date Applied:
Signature:
Building Commissioner/Inspectof-6fBuildings Date
SECTION 1:SITE INFORMATION
1.1 Property Addres :ton-
1.2 Assessors Map&Parcel Numbers
51.1 a Is this an acceptedno MapNumber Parcel Number
1.3 Zoning Informati1.4 Property Dimensions:
Zoning District Lot Area(sq ft) Frontage(fi)
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? Municipal❑ On site disposal stem ❑
Public❑ Private❑ - Check if yes❑ p p system
SECTION 2: PROPERTY OWNERSHIP'
2 Owner'of Recon
t e r c'l P h�r�C+ r�cl 'SCL,. MA
Name(Punt) Address for Service:
C1`Z 6 - -I Lt l C6 y�
Signature Telephone
SECTION 3-.DESCRIPTION OF PROPOSED WORK"(check all that apply)
I ❑ SA
Mes g r 1--lion(s) Addition ❑n . c
Denxilition ❑ 'AccessnryBldg. ❑ Number ofllnils._.__ Other O Spccil'p:_. . ._,_;
Brief Description of Proposed Work':
N y 5E. � m r�. l C`ltic.itC-zS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
].Building $ a I 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/fown Application Fee
2.Electrical $ Q ❑.Total Project Cost' (Item 6)x multiplier x
3.Plumbing $
(� 2. Other Fees:
4.Mechanical (HVAC) $ O List: V
5.Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ t a I a 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES t
5.11 L-ticensed Construe ti(in
1Supervisor(CSL) c
L "'F Y i l [p P j Lice6nse Number Fxpiration Date.
Name of CSL-Holder 1 v 0 s o✓�`� �
ni List CSL Type(see below) t I
A ess Twe U > _ C Des cij lion ,
U Unresmcted(u to 35,000 Cu.Ft.
Signature . `'�— R Restricted 1&2 Family Dwelling
y I - CIl.q -UOti), M Masonry Only
Telephone.
TeleP
RC Residential Roofing Covenn
WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D .Residential Demolition
5.2 Registered Home Improvement Cqntractor( C�
I�Le,[ et.�a\ (h� A,.eJ1erC.e /SLoF� .1�1t:It•�I[j�
H�C Companyy Name or HIC Re istragq�1arr/e Registration Number
� . -) tS Sl IO i'f.1, ,[n and 0 (-T3a
Ad r ss Q t ��-�l 1 o
'DR eYX,t:n .- S'-U`k - cllq-c,;qS- Expiration Date
ignature- �— '�4 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 7at,9WNER AUTHORIZATION TO BE COMPLETED WHE]V`.
OWNER'S AGENT OR;CONTRACTOR APPLIES EOIiBU"I[NG'PERMIT-
I> 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.
Signature of Owner - Date -
SECTION 7b: OWNERI OR AUTHORi?XRD' ;GENT DEMARATiON .
r }. as.O4[gier or:A e A[rnt .rebv rleclate
that the sta enie[i and information on the fog-ruin, apphcaLun a[efrue andacciu'ale, toto the wwledge'and
.behalf
Signature 4th,,
on !.fprqug)
- Dale
(Si ed unnd enalties
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(IBC)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.R6 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 ofbathrooms Number ofhalf/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"