40 FAIRMOUNT ST - BUILDING PERMIT APP 2S C_K R �o�
The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEIVED CITY OF
M
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Massachusetts State Building Code, Igo C PECTJORAL SE IC. EM
evised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
Cr One-or Two-Family Dwelling 11111 DEC _4 P �=
This Section For Official Use Only:
Building Permit Number: Date A lied:
I ' _�
Building Official(Print Name) 't Signature - - bate
SECTION 1:SITE INFORMATION
1.1 yn Property�ddress: 1.2 Assessors Map&Parcel Numbers
rar�moltnt SSf
1.1 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)
From Yard Side Yards Rear Yard
Required Provided I Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.71 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1Ou ecord:DOW� ( �7 /� A
Name(Print) City<,State,ZIP /Y(�'
Nh ,r,�-,aur�� 9�9 gz/- /05
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building 01 Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ ( Number of Units Other Specify: ZA arrn�J
Brief Description of Proposed Work : f
a Zct
SECTION 4j,ESTIMATED coNsTRuc34oN COSTS
Item Estimated
Labor and ater
Costs:ials Official Use Only
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1.Building $ O ,I 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ I ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ l List:
5.Mechanical (Five $
Suppression) Total All Fees:$
�7� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1 DO I ❑Paid in Full ❑Outstanding Balance Due:
S�-tlT 12( q
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Q 15�7-7 y 3 (p
License Number Expiration Date
Name of CSL Holder
Lric W. Polm List CSL Type(see below)
No.and Street Type Description - -
SWe111 MA 0"1970 U Unrestricted(Buildinps up to 33,000 cu.R
R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Maso,
RC Roofing Covering
WS Window and Siding
_ SF Solid Fuel Burning Appliances
D I Insulation
Te �
le hone Email address L D Demolition
5.2 Registered Home Improvement Contractor(HIC) ' Li U�--/
Atlantl(' W08f) C&A'tian,T 1 C HIC Registration Number Expiration Date
HIC Company Name or I'll01 gi e Nam e
No.and Street , MA 01970 SR � Email address
City/Town,State,ZIP 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 permit.
Signed Affidavit Attached? Yes ........ No...........❑
SECTION lac OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby Iauthorize Erl-C 6 a /M
to act on my behalf,in all matters relative to work authorized by this building permit application.
(�� I z,/z _
Print Owner's Name(Electronic Signatu Date
SECTION 7b:OWNSRi OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in is applica' n is trug�and accyrate to the best of my knowledge and understanding.
r 2/�iti
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.Li c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) I (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 I Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"