14 FAIRMONT - BUILDING PERMIT APP y
The Commonwealth of Massachusetts Town of
\\ Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
j One-or Ttt o anti(' Duelling
_ this Section For Official Use Only
Building Permit Nui Date Applied:
Signature:
Buil ing Commissioner/inspector o(Buildings Date
�— ' SECTION 1: SITE INFORMATION
1.1Fir pe Address. 1.2 Assessors Map& Parcel Numbers
!� /e
M Number Parcel Number
1.la Is this an accepted street,yeses a_ no P
1.3 Zoning Information: 1.4 Property Dimensions.
Zoning District Proposed Use Lot Area(sq ill Frontage(R)
1.5 Building Setbacks(R)
Front Yard
Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.U.L C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if Xes13
SECTION 2: PROPERTY OWNERSHIP'
2.1 wit r of Record: /d M /
a Address for Service:
J Name(Print)
9�51
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s)
Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other O Specify:
Brief Description of Prop9jrd Work=:
L�»')daf
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building Permit Fee: S Indicate how fee is determined:
I. Building S dd7 ClStandard City/Town Application Fee
2. Electrical S r' ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 3 r'�d 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amu t: Cash Amount:
6. Total Project Cost: S 14,Joa Cl Paid in Full ❑Outstanding Balance Due:
1)
a
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Constructions Supervisor(CSL) 2 371'
, -LM -�' j f License Number Ex iro ion Dale '
Ngmc of CSL- H Idrr V
-�d )t L,6 a' List CSL Type(sec below)
Address ! T Description
U Unrestricted u to 35,000 Cu. Ft.)
Signature R Restricted 1&2 FamilyDwelling
qy� 1 y 1 S1 Mason Onl
�d..l�� RC Rcsidrntial Roofs Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
Sj,Registered Home Improvem nt Con for(HIC)
X /,ilDl�� .r l�I lrl�r , �i bf �` 1d Z11
' \ HIC Co parr r H gistrant Name Registration Number
Ad
/ /1/ 9l E iration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.J 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
1, as Owner of the ro subject 3 property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent hereby 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 or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
I. 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 no 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 I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) 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 Footage"may be substituted for"Total Project Cost"
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