27 DEARBORN ST - BUILDING PERMIT APP (003) The Commonwealth of Massachusetts
Board ol'Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR. 70 edition OF SALkM
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Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or rwo-Fumily Dwelling
�/� XIBuilding
This Section For Official Use Only
`./� Tt Number: Date Applied: e2"it Cummia r/I s t of Buildings DatSECTION 1:SITE INFORMATION
dress7J�B � �� 1.2 Assessors Map dt Parcel Numbers
ce ted street? es no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arm(sq 11) Frontage(11)
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1,c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yesO Municipal❑ On site disposal system ❑
�/� SECTIONS: PROPERTY OWNERSHIP' ` � (�1 Owe �6H R/� d C��� /91l2Gl_LJ� I-�
Name(Print) —� Address for Service:
r
iMechanical
ture Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check s8 that apply)
Construction❑ Existing Building Owner-Occupied Repairs(s) O Alteration(s) ❑ Addition O
lition ❑ Accessory Bldg.❑ Number of Unib Other ❑ Specify:
Description of Proposed Work%
/�t12 b
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Labor and Materials
Building S I. Building Permit Fee:S Indicate how fee is determined:
trical S ❑Standard City/Town Application Fee
O Total Project Cost (Item 6)x multiplier x
bing S 2. Other Fees: S
hanical (IIVAC) S List: �hanical (FireSsion Total All Fen:S
Check No. Check Amount: Cash Amount:
l Project Cost: S �e� 0 paid in Full 11 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
l.icenst:Number fixpintiun Jule
Name ul(-'St.- l luldcr List CSL f)pe lmv below)
f 0mriotion
Address U Unrestricted(up to 75.000 Co.Ft.
R Restricted IA2 Family Dwellings
Signature M Masonry Only
RC Rc'denial RoofingsCoverings
I'cicpMuie WS Residential Wimbw and SiJin
SF Residential Solid Fuel Burning Appliance Installaliun
D I Residential Demolition
F�;A�J—dmm
e Impnremeat Contractor(HIC)
IIIC Registrant Name Registration Number
Expiration Dale
Ttlephtate
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. / 25 ON
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...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Lautharize
as Owner of the subject property hereby
to act on my behalf,in all matters
e to work authorized by this building permit application.
re of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1 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.
Print Nome
Signalum ol'Ovner or Authorized Agent Date
(SiAned under the pains and penalties of 'u
NOTES:
I. 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 Bg 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 790 CMR Regulations I IO.R6 and I IO.RS, respectively.
�. 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 -
). "Total Project Square Footage"may be substituted for"Total Project Cost"
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