15 DEARBORN ST - BUILDING PERMIT APP • t i1t���r
�\ The Commonmealth of MassachLISCUS UI:
t hoard of 131.1tlding Regulations and Standards %it INR IP \I.I'll
fr M:1SS:1Cht1SCUS State Building Code. 7811 ('N1R. 7"' edition 1'SIN
Building Permit .application To Construct. Repair. Renovate Or Ihnxdish a
K(rur,l.hmwu�
One- ur Tiro-Fun)il v Dtt ellin,q, =1)(6
This Section For Official Use Only
s� Building Pennil Nut er Date Applied:
Signature: ���1-�--_--------
13ui1ding Cummi,ntner/ inspector of Bwldings Date .--
SECTION 1: SITE INFORMATION
1.1 Property :%ddress: 1.2 Assessors Map & Parcel Numbers
Iola Number Parcel Number
I.I a is this an accepted street, yes nu_ p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards - Rear Yard
! Required Provided - Required Provided Required Pro<idcd
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-0 On site disposal system ❑
Public❑ Private ❑ - Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
„fii Owner]of Record:
Name i riot Address for Service:
(R-86)
Siena re Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ L- Other ❑ Spccity:
Br f Description o'Pro used Work':t s. )
1
t
r -an sm �)
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item - (Labor and Materials)
I. Building $ 3 a 1. Building Permit Fee: 5 Indicate hum I-c is determined:
❑ Standard_ City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier - x
i
3. Plumbing $ 2. Other Fees: $
4. 1%4echanical (HVAC) $ - List:-------------------
—
i. Mechanical (Fire, T --
5 otal :\II Fees: S
Su. ressiun)
Check No. Check Amount: ('ash :\nnuun
Total Project Cost: $33�a
❑ Paid in Full ❑ Outstanding. Balance Due:.--------
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) 5?7,33 ��2 0(
/s �rI �P r Lirtnsc \umbeY li'y't-uf;-iu��u Uat.
Name of C'SL- I folder I_ul CSI_l'vpe (see helow)
1 Tv e Dsciipion
Wdre.+ L (hresuuted(Lill to ii.000 Cu. Ft.
R Reslriocd Me' D+tellme
-SILnatu e S1 ma.onrs Only
(qlI2C Re+iJrntial Roolin g('u+roma
:R•Irpinutc \1'5 Itnul:nual \t utdo1% .utJ SiJ in1.
S1= 12c+i Jeiuial Sohd Purl Burnam 1 tth:wce hi.udlaw�u
D ReaJenlial Dt'INII IIIUII
5,� Reg credllorne Improvement Contractor 011C) 1uloo9
rc 7 t SerV 1� � Registration Number .
HIC Company.Name or HIC R,gistrant Name
Address (�$>•7�I'DJ��/d Expiration Date
Signature Tel—epht n "7
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152. 9 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 I - r — as Owner of the subject property hereby
.authorize b'1 -r 7ZoC to act on my behalf, in Lill matters
relaZ&m
his building permit application.
y Date
Signatu ut-Owner
/e t, SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I. J hrlrJ'f t���^B r ZdIrZLA , 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.
r Print Nat
Sienature of Owner or Authplized Agent - - Date !�
(Signed under the .sins and penalties of edu )
NOTES:
1. An Owner who obtains a building permit to do his/her own work• or an owner who hires an unregistered euntraclor
(nut registered in the Home Improvement Contractor (HIC) Program), will not have access to.the mbination
and
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Pro g10,115
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and I IQRS. respectively
' ;When substantial work is planned, provide the information below:
Total flours area (Sq. Ft.) iincluding garage, finished basement/atticN, decks or poichi
Gross living area ISq. Ft.) Habitable room count
Number of fireplaces - Number of hedroom. ----_
Number of bathrooms Number got half/hwhs
rope of he:uing system Number of leeks/ p rcches
Gnclosed
Type of cooling syuem —�
3. "Total Project Square Footage- may be substituted fur 'Total Project