30 FAIRMONT ST - BUILDING PERMIT APP The Commonwealth of Massachusetts 3-1-
Board of Building Regulations and Standards CITY
EM
Massachusetts State Building Code, 780 CMR, 70' edition OF SA
:RE . „J` RevisedJanuar�r
Building Permit Application.To Construct, Repairs 1 OW 1, 2008
One- or Two-Family Dwelling :t 35
This Section For Officiat UJflJQnJUN411 Cl< ACLA_Z:=_
Building Permit Number: Date Applied: /
Signature: 2t17Z✓� � c u,, 7/
l Building Commissioner/Inspector of Buildings Date
110 ZS SECTION 1: SITE INFORMATION
1. roperty Address: 1.2 Assessors Map& Parcel Numbers
5-1-
i.t a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 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 OWNERSHIP"
2.1 Ownert of Recoxd:
30 C/2 r mo n� S E
Name(Print) Address for Service:
E4� !� q __) 8- 7 4 s - 6R3 �
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work Z: —_� L [t h L rr, n o.t,idn t,Lp—y y—{c� n .� Li ne
¬ rvinul � d
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1. Building $ 146VIS . Od 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6) x multiplier x
3. Plumbing $ 2. Chher Fees: $
4. Mechanical (1-IVAC) $ List:
S. Mechanical (Fire $ —
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6,Total Project Cost: $ (r q ❑Paid in Full ❑ Outstanding Balance Due:—
�lh / GU�e �P c�uap l s 1 P AAUCO -TCo CC,.
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
h D�� e 2 13 - l7
License Number fixpimtion Date
Name of CSL-Holder rU
List CSL Type(see below)
Address Type Description
U Unrestricted(up to 4 Cu.
Si azupre—� y R Restricted 1&2 Family
Dwelling
, 1_ t,l r 1 0 M Mason Only
9
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation.
D Residential Demolition
5.2 R rstered Ho a Improvement Contractor(HIC)
�01s h 8 4 Z 8
HIC Company.Ngnieoi-H ICt(iegis ailt Name i Registration Number
Address �� n
��j vl7S( �� t{ � - � 00' Expiration Date
Siv eture Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(.M.G.L. c, 152. § 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 Pon-nit.
Signed Affidavit Attached? Yes ..........\0 No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 2U44- G00"-0, as Owner of the subject property hereby
authorize ��p h n( ��(� to act on my behalf, in all matters
relative to work authorized by this building permit application.
(0 Vi; i (O
.Signature of Owner Date
SECT�IOpN 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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,,_,
Signatus of Owner or Author zed Agent Date
(Signed under the pains and penalties of 'u )
NOTES:
l. 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(RIC)Program),will not 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 1`10.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.FL)_ (including garage, finished basementlattics,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'