22 DEARBORN ST - BUILDING PERMIT APP r. - . i
cK.
The Commonwealth of Massachusetts
°uld Board of Building Regulations and Standards SIATLY OF
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prop@r Ad e O� S 2 Assessors Map&Parcel Numbers 22
L r"
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1.1 a Is this an accepted street?yes no Map Number Parcel Number a
1.3 Zoning Informat10 1.4 Property Dimensions: o� .D
�Fr,7 DEAi n� r—
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) � �
1.5 Building Setbacks(ft) �
Front Yard Side Yards Rear Yard O
Required Provided Required Provided Required Provided ti
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? Municipal On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIPr
2.1 Ownert of Reco d: o a
�rlL TAD �t�vDy M1� e�9Ga
Name(Print) City,State,ZIP
l c v►l°E p e 1 � 979-g�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building K Owner-Occupied ❑ Repairs(s) Alter ion(s),K I Addition ❑
Demolition At Accessory Bldg. ❑ INumber of Units Other ❑ Specify:
Brief Description AProposed Work: � R 0 W
- � 1 c I UM-6 WIS
_tk/
0
4W AM
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials -
1.Building $ d dam, 1. Building Permit Fee:$ Indicate how fee is determined.:
2.Electrical $ ❑Standard City/Towp Application Fee
' ❑Total Project Cost'(Item 6)x multiplier x _
3.Plumbing $ 2. Other Fees: $ -
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$ -
�) Check NO. Cheek Amount: . Cash Amount:
6.Total Project Cost: $ �/v ❑Paid in Full ❑Outstanding Balance Due:
VK'e_�<I P�
btd( � -l9 1_1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 w.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP 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?a-OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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.
Print Owner's Name(Electronic Signature) Date
SECTION Tb:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my time below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
wA"v.mass.Rov/oca Information on the Construction Supervisor License can be found at w�i•�i.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor 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"