4 ELM AVE - BUILDING JACKET q / I'hc C'urnmunwcalth ot'Massachuse is
hoard of iluilding Regulations and Stmidards CITY OF
Massachusetts State Building Code, 7SO CNIR S,\Lli\I
Revi.wJ.11"Jr l/
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or rivo-Familr Umdllinnr
This Section For Official Usc Onlyi
Building Permit Number. Date Applicd:
Buil mg Ilic'u -1 � wne) Signal rc - l ale
SECTION I:SITE INFOR TION
L I Property Address:
t ir { 1.2 Aaesson �Iwp di Parcel NumbNumbers —
I.1a Is s ann accepted street?yet /no 11%fap Number Parcel NumhLr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'n,pu.ld(lye Los Area(sq It) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yurds Rear Yard
Required Pruvidcd Required Provided Reyuind Provided
1.6 Witter Supply:(M.G.1.c.Jo,5 sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal s)stcm ❑
Check if yusO
SECTION2: PROPERTY OWNERSHIP'
2.1 r'of Record:
;a Ac n-r
MandStmet
(Print) Uq•.State,l.IP
Av � fdephone Email A dress
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alleration(s) ❑ Addition ❑
Denwlition ❑ Accessory At, ❑ Number of Units_ Other r84:
Brief Description of Proposed Work=:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
I Labor;and.\Iaterialsl y
1. Building S I. Building Permit Fee: $ Indicate how fee is determined:
2.
Electrical ❑Standard CityiTosan Application Fee
❑Total Project Cost't Item 6)x multiplier
l i. l'tunihing S
. Other Fees: S
J, Mcch.ulical ilf W) S q0cr,
ist:_
t \Iech.....c;t Fire
�u' res.ion) S otal ,\it Fees:
S
Oeck No. ('heck Amount _ Cabh \mourn:
t, Total Project CusC S Paid in Full ❑Outstanding 11,11;mce Dal:
tJoelo/Jz
yo 411121 r 2.D•� as
N-'Y A r-i�i 0f 9 i1 I
r
SEC PION S: ('ONSTRUClION SF.RVICF.S
5.1 Cunstructiun Supenisur Lirnse If 51•) 1Y
/r•'�/h/J /G �f�d.��.(/v..-�. ... license Nwnhar Ispiralia I)aa
N';uuc u(l'SI. I InlJer list l'SL I\pe)sec —..._
No. jnd Srcc
U I InresricleJ I IfuiWin o k10 m iS,tAIU al. It
/1'i✓�- _--.. . . Ke.MricW AC?Fanlil b+wllin
Cityi town.Stare. .II' .\I \Laslm
_ S 7 000' RCICl+r+lin l'n+erin
µ'S window and Siding
SF Solid Fuel Doming Appliances
1 Insulation
fcic hone h:muil aJJrcss D Denu+litiun
5.2 Registered Home Improvement Cur tractor(H1C) / 14 L ?42 /
� i It_ 6aa01Y 111C'R Shttrniun Nwnber 1'.p' uliun Wig
I IIC'C'unlpall!-_jlnlc qr I IIp�CgisD Jlf/' °��—Y
�fl� - )r I 1 D A o u•
No. and Sued Iimuil a Jress
�e�a.rl (�+� o19ir (oi�-SllB-�
City/Town. State 21P rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 132.1 2SC(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...........O
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 00"all`Ie evej l)
to a, If,in al 4irs ref • or rized by this building permit application.
' nt U Icr's wne( I clmnic Sig ) e
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,) hereby attest under the ins and penalties of perjury that all of the information
contained in this application is true and accurate t e be t of my knowledge and understanding.
UOODI{v -
Print Uwncr'. r Authurircd, ycnt's Name I Flecaonic ' gnauua) ate
NOTES:
I. .\n Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program),will rIfd have access to the arbitration
program or guaranty fund under\I.G.L. c. 142A.other important information on the HIC Program can be IUund at
,v.l Information on the Construction Supervisor License can be found at k+)s,+ 111.1, >rs tPs
2. %%'lien substantial work is planned,provide the information below; -
rotal flour area(sy. fl ) . ____.._I including garage. finished basemen(attics,decks or porch)
truss living .area I sy. IL) __-. Habitable room count
\umber of fireplaces ._. Number of bedroomis _ - .. .. . .
Ntimhcr of hathrounls _ _ -- \umber of ludf h;mhs
hpcal'he.atingSyAvnl _ \'unlhcrofJccks, porches
I\pc ol Q+Piing i\iielil tt 1!IKIUsed
(lpcn
t, "haul Pruicct 1;quarc footage tn;l +e •,,h,attuted (Ur"l otal PrujcA Coot"