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The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
q, Massachusetts State Building Code, 780 CMR S,\LEM
Building Permit Application To COUIS(rtict, Repair, Renovate Or Demo ' a
One-or Two-Fumilr Dn ellr ,fir
This Section For Official Use Only
Building Permit Number: Da Applied:
BuilJing Official(print Ntune) - SSignaturepate c
SECTION 1:SITE INFORMATION
I.II �5�Property Addr/es/s: �'r/ 1.2 Assessors Nlap& Parcel Numbers
7 LA�/i. S
I.la Is this an accepted street?yes s-�—no Map Nunther Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Cut Area(sq 11 tt Prontuge(11)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal Check if •cs❑ P system ❑
SECTION 2: PROPERTY OWNERSHIP'
21 Ownerto gecord•
tName(Print) city.Slate,ZIP
No.and Street elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(cheek all that apply)
New Construction❑ Existing Building Owner-Occupied Repeirs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units_ Oth r ❑ Specify:
Brief Description of Proposed Work: C
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
I labor and Materials) Official
I. Building S 07 I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
w o ❑Total Project Cost l liem 6)x multiplier x_
7. Plumbing S d 2. Other Fees: S
4. .Mechanical ill\':\CI 5 List:
S. .\kdwnical (Fire --
Su trcssionl 5 rotal All Fees: S_
Check No. Check Amount: C ash AmounC
6. Total Project Cost: 5 `j -- ------- _._ --
(7`(�0001 0 Paid in Full Cl Outstanding Balance Due:
S
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
c5 / _�_. _- License Number p. puull Date
;
N:unc afC L Iluldcr -.._..—____._—_ i-
List C'SI. ['NPC Isee below) (�
"Type Description
No. and Street
SIC
C Le 1 Restricted
1 2 Family
ti el ing eu. tl.l
R Restricted I&? Pumil Dwcllin
ou-Nfroon,Slue./IP N1 Nlasonr
RC Roofing C'ocerin
__ - W'S Window and Siding
}F Solid Fuel burning Appliances
/ I Insulation
"fele hone Fifiall address D I bemolition
5.2 Registered Home 1 provement Contractor HIC) l�
/ I IIC' Registration Numberapiro um Datc
]TIC C npan) Name or I I Registrant Nu e
NO.an cct -J??�" , y Finail address�s ` if k�
Ci / 'own,State, ZIP 'relc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c, 152.1 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 .......... ❑ No...........
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.
print owner's Name(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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print owner's or JWthorized Agent's Name(P cetronic Signature) Kic
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 no 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
wn"S.ina".�;o% ,�._.( Information on the Construction Supervisor License can be found at}%����.m;ts.g�� ,Ip,
F\11enn substantial work is planned, provide the information below:
r area(sq. ft.) (including garage, finished basement'attics,decks or porch)
ngarealsy. fl.) Llabitableroomcountf lircplaecs \'umber oFbeJroomsf bathrooms Number of halfbadeeating S)Stem N'umber of decks porches"ooling S�Steln .. . Fnelosed _ Open
i. "fold Project Square Footage"nim be Substituted fir''fotah Project Cost-