38 DUNLAP ST - BUILDING INSPECTION JACKET w
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The Commonwealth of Massachusetts RECEIV E0
Board of Building Regulations and Standards INSPECTIONAL BERQ�IC£9
Massachusetts State Building Code, 780 CMR SAI.EM
evised bf r 2011
Building Permit Application To Construct, Repair, Renovate Olaktiffillh'a9 5 2
One-or Two-Farrdly Dwelling
This Section For Official Use OnF
Building Permit Number: Date.Applied:
d to q
Building Olticial(Print Name). St, at, Date
SECTION 1:SITE INFORrNIATION'
L1 Property Ad ress: S�}�C 1.2 Assessors blap d&Parcel Numbers
1.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Tuning District Proposed Use Cot Arca(sit It) Frontage(It)
1.3 Building Setbacks(it)
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: Lg Sewage Disposal System:
Public❑ Private Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Checkif es❑
SECTION2: PROPERTYOWNERSRIP!`
2.1 Op nerrafRecord: rya -70
rime(Print) City,State,ZIP
�g yvNG �y s� fV sT8" Kira
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Allemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: /WSf9I�A- i aN e e e
\ SECTION a: ESTUNIATED CONSTRUCTION COSTS
Itcin Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S �*(Outer Fees: S
4. Mechanical (FIVAC) S List:
5.Mechanical (Fire S 'total All Fces:S
Su ressiun)
Check No._Check Amount: Cash Amount:_
G. 'futul Project Cost: S
X ❑Paid in Full ❑Outstanding Balance-Due:-
Pr I L-EXD
w i
SECTION 5: CONSTRUCTION SERVICES
5.1 Cotistructiott Supervisor License(CSL)
License Number Expiration Dale
Name of CSL Holder I ) V-4 List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings Lip to 35,000 cu. It.
ARC
Restricted 1&2 FamilyDwelling
Citylrown,State,ZIP NilMasontry
Rootin CoverinWindow and SidinSolid Fuel Duming Appliances
Insulation
Tole hone Email addresslii5.2 Registered Home Improvement Contractor
HIC Registration Number Expiration Date
IIIC Company Name or IIIC Registrant Name
No.and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 Is§uance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... 13
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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nmne(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, i hereby attest under the pains and penalties of perjury that all of the information
containe m his ap lication is true and accurate to the best of my knowledge and understanding.
XPrint wner's or Authorized r\gent's Name(ElecLi Ic Signature) DateNOTES:
I. A it 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 NI.G.L.c. 142A.Other important information on the HIC Program can be found at
wvww.mass.go .!Oen Information on the Construction Supervisor License can be tbund at www.niiss.nov.!dU%
2. NVhen substantial work is planned,provide the information below:
Total floor area(sq. R.) ,(including garage,finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
rypeorcoolingsystcot Enclosed Open_
1. Total Project Square Footage"may be substituted for"Total Project Cost"