12 FAIRFIELD ST - BUILDING PERMIT APP (002) - — The("it III Ilk In%kI:J(h of Massachusetts
t` Ii,vrJ „t Building Rrgu Lnions .Ind S(alldarJ, fI ilt
\II SI( II' \I I I1
Massie husetts State IIuJJing l'„Jr. 750('NIR. 7°i edition I �I
Building PCI fit( Appl ieat Ion To Consutwt. Repan. Rcnot aie Or I)rnI„I I'h a
A l fill,- „i Tit o {-',tmih [)it rNinit l - -
f---- Thu .Section For Official Use Only -
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hate .\,,tied:
L I1wIJin_ Perron Nu thee: ------__—_ Applied,
- -------- --- - .
Bw Wmg Gm1111"", net, 111'1v.i�!r III Iluddu!p, Daly
SECTION I: SITE INFY)RM \ PION
1.1 Property Ad .s: 1.2 Assessors Map & Parcel Numbers
Ufa \;usher Pa:"]
.Nwnhri
1 i lalslhtst :ar::cpteJ street ' ,rs no P _ _ —
1.3 7-,otiuk information. 1.4 Properly Dimensions:
l
i Pngn � , •• � Let \rea I,y ill F vr.agr Ihi
Unal� LILfIC( '
11 5 Huildiny Setbacks (1'0 -
j From Yard Side Yards Rear Yard
Required Provided Rcyuucd Prus,dcd Rcyuu eJ Pi,1„JcJ l
j 1.6 %,;aies Supply: LN.G.L 40. §54, 1.7 Flood "Lone information: 1.8 Sewage Disposal System:
Zone: _ Outside Floyd Lund %fumci al ❑ On stte Jis„i,al sy,teut ❑
P,hIL: ❑ Pnoate ❑ Check it G P
SECTION 2: PROPERTY OWNERSIIIPI
�2.1 Owr}e�Ref@rt�G
i .Name IPnntl Address for Service:
Signature Tclephcne —�
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check al at apply)
rDe
C,:nstruetion ❑ Existing Building ❑ Owncr-Occupied ❑ Repa'rs(+) G Aller:mon(r') ❑ I Addw,,n ❑�
olition ❑ Accessory Bldg ❑ Number of Units her ❑ Spcul} _�
f DesaipLon of Pn!puaed Work:= _..._—
I.
SECTION J: ESTINIA'TED CONSTRUCTION COSTS l
`---- Estimated Cuss:
Item (I.ahnr and M:nerlalsl Offia'ialh'.ti¢ Ottly -
I BwlJtng y L Building Permit Fee: 5___ Indicate hit„ fee is JctruninrJ.
❑ Skmdard Ciiy/Town Application Fee
tricot 5 ❑To(at Project CostI (Item 6) x multiplier It
t. Plumhmg 'S ?. Other Fees: 5
1. Merh:mical M V \C 'S I List _--
i. Slechamc l IFue 5
>u ,trcs,u nil
Check Nil __('heck .\m„unt� -----( 'a.h \tin nuu
o rulal Project Cost I ) 0 P.nJ InFull 0 Ouuta nJmg R,, an,r hue _
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5.1
5.2 C is fong I n r( se Co clor (111( �;Is
this affidavit will result in the denial tit the Issuance,)f the building permit.
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Date
SECTION 7b: O"NEWORAUTHORIZED AGENT DECLARATION
(hat (he .statements Ind inttiormaticgri on the It,regoinu .ipphcationaie true and accurate, to (he bcst ,)t mv kno%kiedue and
Prof
�
1. An 0\%ner ikho) obtains a building permit (,I J,I has/her,)wn an,mrier %tht) hires all
1,aj I tl,,,-rs area I Sq Ft I (including garage. finished ha,citenuani,N. decks I,r pir,h-
' (�^`^ /^m-g /«u ,Sv F} Habitable owm `vuo/
| Nu.nher ., o/,p(»/e` Nmnhe',, hedo`.`m.
� N'mihc/ ,t h^m^`'m, --_-- Nomh// III h^|: h/h,
| 1�!|`e .`thumn2 `�`/em - _' Nmnhe/ .'/ .|C.L./ y`,`h"
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