15 DEARBORN ST - BUILDING PERMIT APP (003) 1:7—
The Commonwealth of Massachusetts
ql - Board of Building Regulations and Standards ERevised
Massachusetts State Building Code, 780 CMR, 7t"edition ITY
Building Permit Application To Construct,Repair, Renovate Or Demolish a ary
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: - Date Applied: -
Signature: fh J¢/
Building C mm sioner/Inspector of Buildings Date `'`� b
SECTION 1: SITE INFORMATION
1.1 Proper A�.lir / — 1.2 Assessors Map &Parcel Numbers
1.1a Is this an�Jaccepted street? yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) y Frontage(ft)
1.5 Building Setbacks (it) .
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 2: PROPERTY OWNERSHIP'
2. /(I Alf fr nna Ra7� -,/� XX
Name(Print) ` II,, Address for ervic
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) Iteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Un is Other ❑ Specify:
Brief Description of Proposed Work :
V
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ Wqo 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑ Total Project Costs(Item 6) x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su pression) $ Total All Fees: $
6. Total Project Cost: $ - 7 G Check No. Check Amount: Cash Amount:
l./ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
7L!censed Construct///ion Supervisor(CSL)
r11—i (lj�/� License Number�Holder7i t CSL Type(see below)
6 ` r .cC11A r Tt-I c/ a Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Sign ( �96 M Masonry Only
C� RC Residential Roofing Cover in
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) - , Y G 6 G
HIC Company Name or HIC Registrant Name — Registrati n Num r
Address �ta—'t) E ptration Date
re Signatu Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. M. § 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........... 0 -
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.
Si nature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or AuthoRzc ent hereby declare
that the statements and in.
beha ormation on the forejoing application are true and accurate,to the best of my kno Wledge and
l .
�l
Print Name
Signature o ner or orized Agent Date
(Signed under the pains and penalties of a 'u )
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 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 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" -