69 DEARBORN ST - BUILDING PERMIT APP The Con nionwealth of Massachusetts
Board of Building Regulations and Standards I UR
Massachusetts State Building Code. 780 C'MR, 7"' edition I'.�I[
Building Permit Application To Consu act. Repair. Renovate Or Demolish a Krris J.humm, I
One- or Tvt umrh- Du'cllin,t; 1. '"IS
T Section tr Official Use Only
Building Permit Number: ate Applied:
Signature: 7 2 O 0 ----
ng Commissioner/ p Clot of dings Dale
SECTION I: SITE INFORMATION
1.1 Pr pert Address: 1.2 Assessors Map & Parcel Numbers
1.1a Is this an accepted street'? yes. _— nu_ Map Numher P:ucl N'urvhcr
1.3 Zoning information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area tsy to Frontage(it) j
1.5 Building Setbacks (f )
Front Yard Side Yards Rcar Yard
! Reyuirc equiredJ Provided R Provide) Required Provided
1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Dis o-al System:
' / Zone: _ Outside Flood'Zone:'
Public Private❑ Check if yesB� Municipalpal On site disposal systrin ❑
H _
SECTION 2: PROPERTY OWNERSHIP`
2A Ownerl of Record: /9
/7f/s'✓r�.q �VJC Ntr.rJi'�-••S f0 �I+1.Z � _
Name i Print) Address for Service:
ir
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(.) <71lteration(.; ❑ .\dditirn ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specity: _—_
Brief Description of Proposed Work-:W-5 4 t.dihfDt?A/4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Totai Project Cost (item 6) x multiplier- .x
i
3. Plumbing $ 2. Other Fees: .$
4. Mechanical (HVAC) $ List.
5. Mechanical (Fire $
Suppression) Total All Fees: 5 -
Check No. Cheek .amount Cash A1nn1u:_--
6. Cotal Project Cast: $ % 4VV 0 Paid in Full 0 Outstanding Balance Due __-.-
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSI ) ef< -7 5 "Dk",'elhil-
SigIlLAUleZd'dLicense Number lcNanceof CSt_- IIolder List C'SL"fypc Iscc hclual _c Unrestricted tu t (.iRestricted 1&2
Signature _ M Stasonry Only
_RC Residential Routine C'otenne
rlephone \l'S Residcnlia] WinJuw ,md Snhn_ _
SF ReWeutial Solid Fuel Burning \ppliance In.Lil l:wn
D Residential Demolition
5=ered home Improse enl Conte ctor (HIC)
HIC Color any Nunt-or HIC Registrant NLL,;a Reg:-illation !4umher
rg eon/ A✓ r A_ dfq_-70
'Expiration Date I
Stguuture Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
— a
Workers Compensation Insurance affidavit must be tompleted and submitted with this application. Failure to pnwide
this affidavit will result in the denial of the Iss_•aecc of tee buiidin, permit.
Signed Affidavit Attached'? Yes _........ . No ........... ❑
SECTION 7a: OWNER AUTHORIZAT!ON TC+ HE CON!PLETED WHEN
OWNER'S AGENT OR C_ ONTRACTOK APPLIES FCrR RUILI;IN(i PERNIiT_
1, —— .s Owncr of the subject property hereby
authorize .,_-___:o act on my behalf. in all mutters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, �/ /$r✓t^EC --,--. ;is 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.
i7vKE/Ir /d��"+EL
P mt ame
-Z ' ` /
- / g I
��r2/
Signature of Owner or Authorized Agent � ,r - Date
(Signed under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own .cork, 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 Lind
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations I I0.R6 and 110 R5, respectively.
When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished base mendauics, decks ur porch)
I Gross living area(Sq. Ft.)- Habitable room count _
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of half/baths
'fvpe of heating system Number of decks/ porches
Type of cooling system Enclosed _ Open -_-
3. "Total Project Square Footage- may be Substituted for -To(al Project Cost"