4 EVERETT RD - BUILDING PERMIT APP � - I H - I
e Commonwealth of Massachusetts
( OF
Boaz of Building Regulations and Standards CITY M
Mass chusetts State Building Code,780 CMR S
Revised dMar Mar 2011
Building Permit Apl lication To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number:I Date pphed:
1 -Lo
Building Official(Print Name) - Signature - - _ ate �.
SECTION 1:SITE INFORMATION c7 .
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
t Z
1.la Is this an accepted street?yes no Map Number Parcel Number r
1.3 Zoning lnformationl 1.4 Property Dimensions: D rn -
7
Zoning District Proposed Us tat Area(sq ft) Frontage(ft)
1.5 Building Setbacks(It) W
Front Yard I Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G. c.40,§ 4) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSIIIP'
2.1 Owner'of Record: S[t I /1 ycj On G
h 1' ✓G
Name(Print City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Euisting B filding❑ Owner-Occupied ❑ Repairs(s) ❑ eration(s) ❑ Addition ❑
Demolition ❑ accessory Bldg.❑ Number of Units_ Other Specify:
Brief Description of Proo,osed W":
� G
I
I
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Est mated Costs: Official Use Only
Labo and Materials
1.Building $ ' 1. Building Permit Fee:$- Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing i $ 2. Other Fees: $
4.Mechanical (RVAC)I $ List:
5.Mechanical (Fire I Suppression)
$ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: ❑Paid in Full ❑Outstanding Balance Due:-
(I
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder BTIc W.Palm
Hilton Sheet List CSL Type(see below) (A.
No.and Street S,,dem MA 019 00 Type - Description
U Unrestricted Buildin s u to 35,000 cu.ft.
Cityfrown,State,ZIP R Restricted 1&2 Family Dwelling
M Maso
RC Roofin Coverin
WS Window and Sidin
.7ytt,G` - SF Solid Fuel Burning Appliances
D I Insulation
Tee-phone Email address D I Demolition
5.2 Registered Home'Improvi ment Contractor(HIC)
HIC Company Name or 141C e g� e fion+ HIC Registrafion Number Expiration Date�a N6311 Avenue
No.and.street , aj� 01 970
(1 y.5/y Email address
Ci /Town,State,.ZIP Telephone
SECTION 6:WORKE 'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insuran affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the d trial of the Issuan of the building permit.
Signed Affidavit Attached? es .......... No...........❑
SECTION 7 :OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT '
I,as Owner of the subject proper ,hereby authorize ` riI C Ca llnrt
to act on my behalf,in i II matte relative to work authorized by this building permit application.
Print wner's a(Elechnnic Sig ature)
I Date
'SIi'CTION b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I he reby attest under the pains and penalties of perjury that all of the information
contained in this application is 9n ie and accurate to the best of my knowledge and understanding. V/
's or Authori d Agent'print( Name(Electronic Signature) /�Date--+--
NOTES:
I. An Owner who obtains a bui ding permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home I nprovement Contractor(HIC)Program),will not have access to the arbitration
program or guaran fund on ler M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oc Informa on on the Construction Supervisor License can be found at www.mass sov/dos
2. When substantial work is pla tried,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.j 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 Footagi may be substituted for"Total Project Cosf'