1 DUSTIN ST - BUILDING PERMIT APP JACKET 4 .
� � Thc (�ununun���callh ul�qassaehus�tts �:�rl. �
_� e , �� �„ . 13u:ir� u( 13uilJing Kc��ulatiunti ;ui� titunJ:ir�s � \II 'VIl'1.1'.\I.I�II� '.
1.�`� i� Muss:ichusetts State 13uilding Cude. 7;iU ('NiR. 7"' e.litiun i '.tii[ '�
+. �• :
i
.�� Building Pcnnit Applieation To Consuuct. Rep�ir. Rrno�:u� Or I)rnwlish :i Kr:,,,Jhun�.n, ,
Onr- nr T�ru-f'm ' �����Ilin,t l. _uuS j
---i
l'his Ser ' m F� Ofti i�l Use Only �
I3uilding Ptrmii Numbe . � Date plird: _ ---------�—.--�
� �9 ��— �- �--�-- I
)I_p:11U1'2: � _ '-'-�' " . �
Ruddi c um iisniunar/ In�prriur o wW�n� U:tlr ___
-- ---�
tiGC ' . 51'1'E INFOK\L�'CION —--._-._--_
L1 PTrop',c.r1h,• :\ddr•ss: I' 1.2 :\+sessms Dlnp & Narccl Vumbcrs ,
I dJLk71�n �PPT -- -----
I.I a I� �hia :m :ircepted s[nr[? yes_ nu_ .tilap Numher P:�rcrl �\umhrr
L3 Zoning Inform•rtion: lA Property Dimrnsiuns: �
Z��ning L`uiricl Prupused Use Lut Are�Isy (tl Froni:iec ilti ,
� 1.5 Building Setbacks (ft) `
Frunt Yard Sidr Yards - Rcar Y'wJ
! Reyuired Provided - Reyuired PruvideJ Heyuircd Pru��i�cJ .
1.6 W'ater Supply: IM.G.L c. 10, §51) 1J E'lood Zone (nforma[iun: - LS Sewage Disposal Systrm:�
Zone: _ Outside Fluod Zone° . �y�unicipal ❑ On site dispusal systein ❑
Public ❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP�
2.1 Owner�of ecurd: -
I �(�S�IYI `�''�2-�
Nmnc i P - Address for Service: -
(�l"l8� 7H�-t -��H7(o _
Sien� r� � Tcicphune��
SECT►ON 3: DESCRIPTION OF PROPOSED WORKZ(check all that upply)
New Cunstructiun ❑ Existin�: Building � Owner-0ccupied ❑ Repairs(s) ❑ :\heratinn(s) . :\JJiii�m O
Demuliliun ❑ Accessury Bidg. ❑ Number uf Units I Other ❑ Specil'y: �
Brief Descriptiun of Prupused Wurk'": w' � —
SV1S+Q I1 ^h�12 'L1 A I�Y1P �,�.I ��-S -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Escimaced Co,cs: Oflicial Use Only
. I fiem �Lab��r:md Mattrialsl � _
L [3uilding $ �$ G,.� I. 6uilding Permi[ Fee: $ In�ica�e hu�a (ee is J�icrmined: i,
❑ St:indard Ciiy/Town ;\pplic�tiun Fee
?. Eleetrirul `� ❑"J',�tal Project Cost� (Item 6) x multiplier � '
1, f'lumbin�+ S �. Othzr FetS: $ I
� �. ,�terhnnfcal iH�':1C) '6 Li,c � -- �
�. Mcchaniatl IFire � �
f,+tal :\II Fers: 5
Su� res�i��n) � i
� Check Vo. Check .-AinuunC (�,�>h :Am�,une--.--- �.
c�. To[al Pru'ut Cost: '� I g 835�� -----
� i J ' � ❑ P�id in Pull � ❑ OutsuinJing f3:il:inre f)ue:---.__-
� SGCTfON �: CONSTRUC"PION SF.RVICF,S _�
�.1 Licenscd Cm�struction Supervisor(CSLI
� /1 -.5�-7-s3�--- �/ac.a�c� F� .
_l hr�5.�-oDhax '7,nrZ/ f Liccn.c \'uinbtr li�pir.w��n U:uc s
�� j—_—
Namc�il C'SI_- I ulJar _ .
i(5 nl LuICSLl�pcisrdhclu�c)
� \�Jr ^ , I v c . Drscri �u�in
`F / A l� l.'nrrslrirlr� iu i in i;.UUO Cu. 1=1.�
� � ����i� . R � RrsirincJ I.@_' F.mul� D��rllinm
� Sianatur• )1 \t:monr� Unlv � —�
� � � RC Rra��iniiul Kuulinu<lnrrin¢ I
'Irlephon�• \l'S NniJrulial \Fin�u�� .inJ lidine .. .�
. , . , SP Rc.iJtmial tioh�l l��.irl liurnin,� \ >>li;m.� Iu.i.Jl.w��ii�
' � D Rc.i�rnli;�l Urmuliw�n '
' �1 Registered Ilomr Imprurrmen[ Con[roctor U�IICI f p� ��
A� � SPt'vLC2g .TnC
HIC Cumpuny Name or HIC Rc�istrant \amt Ra�utra�iun tiwubrr
Addr•ss / �O'o2� �a _—
� � � 1-� Fepu�auun Ualc
I Siflnatw�e Te cphune
SECTION 6: WORKERS' COM1IPENSATION INSURANCE .4FFIUAVIT(ht.G.L. c. t�2. § 25C(6))
�Vurkers Compensatiun Insurance �ffidavit must bt eumplered and submitted µ�ith ihis .ipplicutiun. F:ulurc tu prucide
this affidavit will result in �he denial u(the Issuancz uf the building permiL �
� Signed Aftid.ivit Attached'? Yes .......... No _......... ❑ .
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[: ��`b� ('� Pf�V�/�r�j , as Owner uf the subject property hereby �
uuthorize tu act un my behalt: in :ill m;itters
rela[ive tu w �YI uthurized b i is u Iding per ' .pplication. „
r � ��//�b �
—�
Sienalur ul Owner D�ie-
SECTION 7b: OWNER� OR AUTtIORIZED AGENT.DECLAR,ITION
[. �r��-f7�nu��Y ��rLUI , as Owner ur :�u[horized Agznt liereby ilerl:ire .
[hat the statements and infurmatiun un t fureguing applirutfon are true and accurate, to the bes[uf my knuwled�te and
behalf.
- � I P��in�� , . . � ' / /�/ /Q/J . . .
' � DILf1:1IlItCUIVWI1Cll 'h1U1iiUlIGCt�:�gC��i C�i�' .
�Siened under ihe ains and enaltics al .cr'ur ) .
NOTES:
. I. An Owner ���h�ubtains a building permit to dn hia/her uwn «�ork ur an u�ener wh�o hires un unregistered cuntraciur
(nut registered in the Home [mpruvement Cuntractur(HIC) Pru�raml, will ao! ha.�e accesv t�i.the orbitr:ninn
, � program ur g�u�ranty fund under M.G.L. c. f-t'_'A. Other impurtani inturm:uiun on rhe HIC Pmgram :ind
Constru�'tiim Supervis�ir Licensing (CSLI can-be found in 750 CNIR Regulutions I IO.R6 :ind I IO.RS, respeetivelV.
' '- When nubstuntial work is plunned, pruvide the intixmatiun bel�'�w: �
I �fntal fluurs area 15y. Ft.i � lincluding gara��e, finished hasemenUattir+. �trks ��r p�nrlu � .
; Grosa living urea i5q. Fe) _ H;ibitable ru��m �uuni - .
Number uf(irrplares � . iJumber uf br�nwm. -------- I.
Num6er uf baihru�,ms Numbzr�,f halt7h:uh; .--.--- _
� f e�pe uf he:ilin� iysiem . ---- . �luinher n(.ltrk�/ p��rnc�, __ _ i .
�Cype ��f euuline s}��ICm 1'nrlu�rtl ()��cn ._.__— — __ '
3. 'T�uul Project Squ:u�e Fu��tngt., m�y be ;ubstituted tim -'T�rtul Prnjeet C��ot" � . �
�
id r
0 The Commonwcahh of Massachuscus Town of
Board of Budding Regulations and Standards
Massachusetts State Building Code, 780 CMR. 7'a edition Building Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a gid►
r- or Tyco-Funah Dwelling
This Section For Official Use Only
Building Permit N mbec Date Applied: U
Signature: OA/2
Buildin o issioner/Ins Busldmgs Dale A ��— r`
SECTION I:SITE INFORMATION
1.1 Property Address- S c/ 1.2 Assessor Mop 6 Parcel Number
1.1 a Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Arca(sq R) Frontage IN
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided- Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information. 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici O On site ilii sal s stem Cl
Public O
Private O Check if s0 Do Y
SECTION 2: PROPERTY OWNERSHIP'
2.t OwneriolRetordS
: // /
-; P S �n Ucuf<pS �GAf4 Xe �C /
Name(Print) Address for Service:
zy4 3 N7 G
signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O 1 Repairs(s) O 1 Aiteration(s) O Addition O
Demolition 0 AccessoryBldg.O Number of UniU_ Other O Specify
Brief Description of Proposed Works: 5- '.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building f 1 I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
1 Elecincal f O Total Project Cost'(Item 6)x multiplier
J Plumbing f 2. Other Fees: f
O. .Mechanical (HVAC) f List:
S Mechanical (Fire f
Total All Fees: f
Su ression
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: f ��- 0 Paid in Full 0 Outstanding Balance Due: SII
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supersis r(CSL)
'• .0 ��.�� S to _ L .enx Number Espu tion Date
N. of CSL 149W / Lid CSL T
Ya laee bclowly
T Descn tion
A o >!
UI Unrestncted u to JS,000 Ca Ft.
Restricted 1&2 Fam
Mason Onl d Dwelling
Signature— L �S3 .N
.Z 7 _ 7 l S / RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burnims Appliance Installation
D Residential Demolition
S.2 Regbtered H me pr erneq Contractor(HIC) / 5 L�
HIC Company Name or HIC egtsuant N / Registration Nuu'mber
A J U
Expiration D to
S' nature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.§ 25C(Q)
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 ARdavit Attached? Yes.......... O No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, ,/el 1 ,6as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work
utho 'ze
/ s building permit application.
o
Signature of Q0ner 1 Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATIO
7 n ciL ,as Owner or Authorized Agent hereby declare
that the statements and information on theforeg ing application are true and accurate,to the best of my knowledge and
behalf.
�J r�—
Print Norte
161J-V(5
Signature of Owner or Authorized gent Date
(Sillned under the pains and penalties of r'
NOTES:
1. 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 rig have access to the arbitration
program or guaranty fund under M.G.L. c. 141A. Other important information on the HIC Program and
Conswction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I IO.RJ,respectively.
2. When substantial work is planned, provide the information below;
Total floors area(Sq. Ft.) (including garage, finished basement/anics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
,Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Tv pe of hearing system Number of decks/porches
Type of cooling system Enclosed Open
3 Total Pro)ect Square Footage"may he suh,muted for 'Total Project Coat"