1 DEVEREAUX ST - BUILDING PERMIT APP t t
� The Commonwealth of Massachusetts �.nR
�� I Board of Building Regulations and StandarJs �
� ,n MUNII'IP:\LI'I'1'
`,,F�� Massachuset[s State Building Code. 780 CMR, 7 edition �S
USE �
Building Permit Application To Construct, Rep�ir. Renovate Or Demolish r Rrri.sed Junuu�.c
Orte-or Tx�o-Frarrrlv Dk•r!lrng �' ��X�`� \`
This Sec�ion For Official Use Only �
Building Permit Num r: Date Applied:
Signuture: �� /6 4� �
Bu' i mmissiuned Ins ctur of Buildings Dute
SECTION 1: SITE INFORMATION
1.1 Property Addy�s: �� ,�. � 1.2 Assessors Map & Parcet Numbers
L l•r Is�his an accepted stree['?yes_ no_ Map Number P;ucel Numtur
S 1.3 Zoning Intormetlon: 1.4 Property Dimensions:
Zoning District Propused Use Lot Area(sq R) Frontage(tt)
1.5 Building Setbacks(ft)
- Front Yard Side Yards Re;u Yard
Reyuired Provided Required Provided Required ProviJeJ
1.6 Water Supply: (M.G.L c.40. $54) 1.7 Flood Zone In[ormetion: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP�
21 Owner� otid: �
vJ
Name(Print) �., -/� � Address for Service: fr
L�_� '�`f'��7f'j�
Signa[ure Telephone �
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check allrthat apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) '0 Alreration(s) ❑ Additiun ❑
Demolition O Accessory Bldg. O Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work2:
Y
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Officlal Use Only �
[tem (Labor and Materials)
l. Building $ � I. Building Permit Fee:$ [ndicate how fee is de�ermined:
O Standard City/fown Applic•rtion Fee
2. Electrical $ p Total Project Cost3 (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mcehanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Su ression)
Check No. Check Amounc Cash Amount
6. Total Project Cost 8 �� I.� ❑paid in Full 0 Outstanding B•rlance Due:
��-c� � ��,�r��Lr�
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Nance of CSL- Holder
List CSL Type(see below)
Address T Description
U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Ugm 1 r ve t Con .actor(HIC) Ilrr2
HIC Q y Na or klC istr, t ' e Registration Nw her
Address Lb"I-�33
-
Expiration Date
Signature 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 Issuan• of the building permit.
Signed Affidavit Attached? Yes ..........d No........... 13
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, ,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 Name/
SigAimre of net or Authorized Agent Date
(Signed unde the pains and penalties ofperjury)
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 not 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 780 CMR Regulations 110.116 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basementlattics,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"