51 DUNLAP ST - BUILDING PERMIT APP JACKET 2-0 9 _ ' Lk eV, 4(0 2>9 ,q�
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SALENI
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Buildin PermitNumber. Date ppliedt
wilding Official(Print Name) - Signature Date
SECTION 1:SITE INFORNIA ION'
1.1 Property Address: 1.2 Assessors Nlap 3c Parcel Numbers
®U1V Z 13 P ST
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private Cl Zone:
if yes❑ Municipal ❑ On site disposal system ❑
SECTION2:' PROPERTY OWNERSHIP''
2.1 Owner of Record:
-I a- m£�T s c � t s f�L f=r\A nit P 0 I �► C�
me(Print) City,State,ZIP
�78-7yy-l/ 5-
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply).
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) 01 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units1_ I Other ❑ Specity:
Brief DescriypW.pn of Proposed Work': aura r- A W-1 R— Lam. -
eO€2f-OttJG, i- X,ST;w� 7Lc�o SLYLiG�s'�sLlJiLL
ep
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials) Official Use Only
I Building $ I. Building Permit Fee:$ -Indicate how fee is determined:
Electrical $ ❑Standard City/Town Application Fee
�. -
- ❑.Total Project Cost?(Item 6).x multiplier. x
3. Plumbing $ 2. Other Fees: $ /�`�l
4. Mechanical (HVAC) S List: . ,�y6b
5. Mechanical (Fire S Total All Fees:$
Suppression)
77 Check No. - Check Amount: Cash Amount:
6. Total Project Cost: $ �00>' 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Q go 3q
fAL)-�)1 J—L4 F-La License Number Expiration Date
Name of CSL Ilolder U
List CSL"type(see below)
No Street . Type Description,
U Unrestricted2 Family
(Buildings u el ing cu. it.)
R Restricted I&2 Famil Dwelling
Citylfown,State," M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) `O �� T
/hFGr0S CDAJ TiPOJCTO {l� 4-L C— _ HIC Registration Number Expiration Date
II LC Company Na r HfC lje ist a Name
ad t�-��//Ili�l�' Gi 2. �i9tlsi�'N2d��Go�H/sv copy
e/nn A /J/O a Email address
City/Town,St a,ZIP 7!� i Telephone
SECTION 6:WORKERS'COMPENSATION.INSURANCE AFFIDAVIT(M.G.L.c.,152.¢f 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 .......... Cl No........... ❑
SECTION 7m OWNER AUTHORIZATION TO BE COMPLETED W HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
tot act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION7b:OWNER'OR AUTHORIZED-AGENT DECLARATION
By entering my name below,1 hereby,attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
�u,sIr`No A-L, L0 8 - 29 - 13
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.m11-11 ov:'oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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 heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'