14 EDEN ST - BUILDING JACKET The Commonwealth of Massachusetts ary
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Board of Building Regulations and Standards SAL M l � Massachusetts State Building Code, 780 CNIR dMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This Section For'Official Use Only
Building Permit Numbers Date A lied
7j
Building Official(Print Name) gnature Date.
SECTION I: SITE INFORMATION.
1.1 Property Address: 1.2 Assessors Map 3c arcel Numbers
l.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 fit) Frontage(ft)
1.5 Building Setbacks(fit)
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: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public ❑ Private❑ Check if yes❑ Municipal ClOn site disposal system ❑
SECTION 2; PROPERTY'OWNERSHIPL
2.1 Owner'of Record: a ( 9 ��1 yam/ Q 7 p
Print)Name City,State,ZIP
J/ � 973- 7i!S-/3.51
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied . Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ke V JT/' [/
VkjS'TALL C /2 LC
SECTION 4: ESTIMATED CONSTRICTION COSTS-
Estimated Costs:
[rem Official Use Only
Labor and Materials
I. Building $ I Building Permit Fee S Indie3te how fee is determined:
❑Standard.CityiCotyn Application Fee.
2. Electrical .$ - - -
❑ Cotal Project Cost (Item.6)x multiplier. x
3. Plumbing 'S 2. Other Fees:'S
I. Mechanical (lIVAQ $ List:
5. Mechanical (Fire $
S up pression) Total :kll Fees: S
Check No. Check Amount Cash :\mouut
6 fatal Project Cult $ 91 yD I. ❑ Paid in Full 0 Outstanding 1hiince Due:
r
SECTION 5: CONs'fRUC ION SERVICES
5.1 Consh•uction Supervisor License(CSL)
FAJS-r1Ma MEL-O _ License Number Expiration Date
Namc of CSL I Iolder
List CSL Type(see below)
31 v-rreIV N I AJ6 S 12 Type Description
No. and Street
PEA113D 0 � �7 A ®l2 a � U Unrestricted Buildin s unto 35,000 cu. ft.)
R Restricted 13c2 F;unil Dwcllin
City/"Town, Stutz, ' iI �Luonr
RC Rootm Coverin
1VS Window and Sidin
a_ / / pp) SF Solid Fuel Burning Appliances
97,8-53i-6?,T l r-ousJJND/YI£Lo��1SH/r 1 Insulation
Telephone Email address 4.6M D Demolition
5.2 Registered Home Improvement Contractor(IIIC) i C) 995 3 R 721R—A/
MF-i-01S GO/&sl feac-r Z.L G F11C Registration Number Expiration Date
I IIC Company Name or NIC Registrnnt Name �f �1
_ L3 ��IV riJ ikJ l S C' ire' rAUfJ +jAM14IL® &2"COOYJ
No.and Street Email address
City/Town,Sta e, ZIP 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 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
I, 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 th s f my kno%y d understanding.US7"i�b /LIGLa L�� �
I' nt ownerb or Authorizal:\;znt's Nano(Electronic Signature) `� Date
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program can be found at
a ww.ntass."ovfoca Information on the Construction Supervisor License can be found at www.mass.,ao�`d}t
2. When substantial work is planned, provide the information below:
Total floor area(sq. fi.) _ — (including garage, finished basement/attics, decks or porch)
dross living ;urea(sq. 11 _ hfabitable room count
Number of fireplaces----- Number of bedrooms ------ ---_--
Number of bathroottts Number of halbbaths --— _
1'epe of heating system
--------------
I'ti pe of Cooling systcnt
1. '-f"tlal Plojcc't.squirc Euols,e" may be stibttinacd for 'hntal Project Cont" -