34 DEARBORN ST - BUILDING PERMIT APP The Commonwealth of Massachusetts IVE0
'u4s Board of Building Regulations an 1 tag :1 1@ p SERVICE, CITY OF
EM
Massachusetts State Building Cade, $b R Sd Har
/�� ��. Revised Mar 2011
Building Permit Application To Construct,Repair,l2 v�k ben&isIO
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date ppAAlied:
`Y ,
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
11 p4ppeaty rays:�/�/y� �t� 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
O erl of ec r
kQJ
Name(Print) Cuy,State,ZIP s
34 L7e�rn ?+-- 7C73 5 3� 9 R� i�6a, �cin�cl[w+'
No.and Street Telephone Email Kddress
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Constmetion ❑ Existing Building❑ Oumer-Occupied ❑ Repairs(s) ❑ 1 Alteralion(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work: I _I
iZ P d
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
1.Building $ 1 1,4 dsl. a a. 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical
❑Standard Cityfrown Application Fee
$ QQ
❑Total Project Cost;(Item 6)x multiplier x
3.Plumbing S GO 2. Other Fees: $
4.Mechanical (HVAC) $ "l0 00 List:�5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount
6.Total Project Cost: S ,all ❑Paid in Full ❑Outstanding Balance Due:
/ 1
Opt' "V,',
1
1
SECTION 5: CONSTRUCTION SERVICES
5.1 C nstruction Supervisor License(CSL) �//�O�r
License NumberExpirats�Jun Date O
Name of CSL Holder
o Woo U I blf— List CSL Type(see below)
NQ�and Street V�1 Type Description
C .� ( m /�/�� Q�-s"�/ U.� Unrestricted(Buildings up to 35,000 cu.ft.
` Ci—ty/T/o`tx/nl3tate,7-1P( z 1, ` R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
S��S t-' f�'�OrrS�Zcnf7n6C2� It T Insulation
Telephone Email address D Demolition
5.2 Registered Improvement Cont actor �,� ^O.� 4--(�-
� Qse—
/�U lam]Cont
HIC Registration Number Expiration Date
H1C pan arc or HIC Regi'[ran[Name
No.a ree[ ail address
City/Town, State,ZIP �+Y1� 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 7a: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.
� icl) �t4))&e,-,
Print Owmels Name(Elecvomc Signature) Date
SECTION 7b:OWNER` OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and occur i1wbest of my knowledge and understanding.
q�13114
Print Owner's us-Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an ovivner 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
Information on the Construction Supervisor License can be found at
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 hearing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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