0007 FAIRVIEW AVENUE - BUILDING PERMIT APP The Commonwealth of Massachusetts Town of
Us Board of Building Regulations and Standards
.'Massachusetts State Building Code, 780 CMR, 7ih edition
Budding Dept
Building Permit Application To Co �Repair, enovate Or Demolija
One-or T o-Fu
This ection For O ial U- Only
Building Permit Num r: to Ppli :
Signature:
Building Commissioner/Ins for of Bu X
ings at
SECTIO •SITE ORMATION
I�Pr erty i ess�., J
PC a 1.2 Assessors Map& Parcel Numbers
7�
Par
I.is Is this an accepted street'.r yes_ no [MapNumbcr cel Number
1.3 Zoning Information: 1.4 Property Dimensions:
.Zoning District Proposed Use Lot Area(sq It) Frontage In)
rture
ing Setbacks(ft)
Front Yard Side Yards Rear Yard
d Provided Required Provided Required Provided
Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Private O Check if es❑ Municipal ❑ On site disposal system ❑SECTION 2: PROPERTY OWNERSHIP'
rf Rec) Address for Service:
�1 L-76�tf)Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) Addition
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief scription of Proposed Work': 2 V2- I a` Q
l'!z
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Of►Icial Use Only
Labor and Materials
1. Building S � 000 1. Building Permit Fee: S Indicate how fee is determined:
` ❑Standard City/Town Application Fee
2. Electrical S O COD — ❑Total Project Cost'(Item 6)x multiplier x
O J. Plumbing S /^o i _ 2. Other Fees: S / / \
4. Mechanical (HVAC) S �� List: 11Y )
5. Mechanical (Fire S
Suppression) Total All Fees: S
�. Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S 6�U ❑ paid in Full ❑ Outstanding Balance Due
�� '��Ian •�ya�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) C,w n2
Eli 1— 64 ��'d Lic=cmc Nu'Zmber Expiration Date
N.4mc of CSL- Hylder (� List CSL Type(see below) --
,..�,s
Address Q-pj-t w!44- D'+—�ls� T Description
U Unrestricted u to 35.000 Cu. Ft.)
R Restricted 1&2 FamilyDwelling
Si re M Slason Only
7g I_`/Zj�-7�f�7 RC Residential Roo0n Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 RegIs Home Improvement Contractor(HIC)
IF G LUG "7
HIC Compan Name or HIC (tegist t Name / Registration Number
/l1 /tl�1C.C��- Garr 02.q /O/l /05�
Add e
-)y(—rjZ`j—']ro' Expiration Dam
aturc Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.9 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........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
), 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
=thepains
ECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
ents and information on the foregoing application are true and accurate,to the best of my knowledge and
w s eJ ��C 3tk7v as o
ner or Authorized Agent Date
he ains and enalt",of per u
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 fW 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 IO.R6 and I IO.RS,respectively.
2. When substantial work is planned, provide the information below:
Total no
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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