5 EVERETT RD - BUILDING PERMIT /I The Commonwcallh of Massachusetts
r Board of Building Regulations and Standards Town of
JMassachusetts State Building Code. 780 CMR. 7"edition Building
Building Permit Application To Construct, Repair, Renovate Or Demolish a tgll ods ,
One-or rtru-funtilF Duelling ANN&
This Section For Official Use Only
Budding Permit Number: sit Applied:
Signature: 3 /7
Bmldtng Commissioner/Inspector of Buildings we
SECTION 1:SITE ily#400ATIoN
1.1 Property Address: / 1.2 lessors Map 6 Parcel Numbers
�v+✓fir.e TC ��Otl�f
1.la Is this an accepted street:'yes no Map Number Parcel Number
I.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq R) Frontage(it)
1.3 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)t1f.7Zone Information: 1.8 Sewage Dispoeal System:
Public 0 Private O Outside Flood Zone? Municipal 0 On site disposal system 0
Check if es0
SECTION 2: PROPERTY OWNERSHIP'
2.1 n�wnjtr,of RecordJ�
Name(Print) Address for Service:
So b ZI (6 Z-! 8 9Q
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction 0 Existing Buildi Owner-Occupie Repairs( Alterations) O 1 Addition 0
Demolition O Accessory Bldg. O Number of Units_ I Other 0 Specify
Brief Dexription of Proposed Work': S T-,Z r3 w.S inn
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OHlclal Use Only
Labor and Materials
I. Budding f I. Building Permit Fee: f Indicate how fee is determined:
2 Electrical f 0 Standard City/Town Application Fee
0 Total Project Cost (Item 6)x multiplier x
Plumbing 2. Other ther Fees: f�(�
a. .Mechamcal IHVAC) f List:
s Mechanical (Fire S
Su presston Total All Fees: f
/ Ov Check No. _Check Amount: Cash Amount:_
6 Told b
Project Cost f ( 9 0 Paid in Full 0 Ouuundtng Balance Due:
r ,
SECTION S: CONSTRUCTION SERVICES
3.1 Licensed Construction Supers isor(CSL) 0 9(k l
O b�Lv S Lrcerne Number Espuation Dale
N.yor of CSL Hylder
I U R�') !1 i ,✓ Ci i� `-�..d (t1pD V LiH CSL Type(xv helowl
i Description
A Jdrcsl_ __
U Unrestricted(up to 35,000 Cu. FI.
R Restricted IR2 Family Dwellm
Sgnartot M Masonry Only
I -ZI,-t.4 RC Restdcntwl stooling Covering
Telephone IS
Residential Window and Siding
� SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
3.2 eglstered Homo Improvement Contractor(HIC) O D }
HIC_J Na�w HIC Rrgts� ��G,_ Registration Number
lam r t� �'T P o b4 re
A
,� �_ 9'75� .�'31Ra3y Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 132.f 23C(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.......... O No...........O
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.
Signature of Owner Date
/S-+ECTION 7b:OWN�ERI OR AUTHORIZED AGENT DECLARATION
LT r -01-. r i/ �Ae-( ,as Owner o Authorized Agent ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner od&mlh iz A en Date
(Signed under the pains and penalties of
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R3, respectively.
2. When substantial work is planned,provide the information below
Total Moors area(Sq. Ft.) (including garage, finished basementiattics.decks or porch)
Gross living arcs(Sq. Ft.) Habitable room count
Number of fireplaces Vumber of bedrooms
Number of bathrooms Number of halLDaths
Type of heating system Number of decks/porches
Tspeof cooling system Enclo.ad Open
1 -Taut Proect Square Footage"may he .uhsmuicd for Total Project Cost"