21 FAIRVIEW RD - BUILDING PERMIT APP (002) t eo
fhe Commonwealth of Massachusetts ECTI(�NA
CITY:OF SERVICES
Board of Building Regulations and Standards R�n A, 1VI � ES
Massachusetts State Building Code, 780 CMR t+
1►: 3
Building Permit Application To Construct, Repair, Renovate Or Demolish a Q
One-or Tiva-Family Dtve!ling
NThis Section For Official Use Only
Building Permit Number. Dat pplied5
!DatiBuilding Otlicia)(PrintName) tgnattue•:
SECTION 1:SITE INFORh1ATION:
1.1 Properly Address: 1.2 Assessors Nlap& Parcel Numbers
I.1 a Is this an acce ted street?yes v no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq 11) Fromuge(11) - .-
1.5 Building Setbacks(R)
Front Yard - Side Yards Rear Yard
Required - Provided 'Required - Provided. Required Provided
1.6 Water Supply:(M.G.L e.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal E3 On site disposal system O
_ -
Public 0 Private O. . Check if esO P-
SECTION Z: .PROPERTY OWNER31I111!`
2.1 OwnertofMRccC� �ard: ' /Cc
� �f d�r..� Y .iLo ��ril r��
N)me(Print) - City,State,41P .
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK°(check all that apply)
New Construction O Existing Building Owner-Occupied 21Repairs(s) Altemlion(s) 17 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': (1 yrov-e C+1eIS Cne Rn52ranvT PAN°L1n3 wr�J
_5h- 4-mcrt yiwt u..e_1ts _ R.�i.ac I_Hl�e h�rrd t Sk�a� PLnSt�R
110 rn A,vo I Ve It
SECTION 4.ESTIbIATED CONSTRUCTION COSTS
Itcm - Estimated Costs: Official Use Only
Labor and Materials
I. Building S 5 O0 °o I. Building Permit Fee:$ Indicate how fee is Determined:
�. Electrical S Building City/Town Application Fee
3OO o ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing S 2`?Qlher Fees: S
4. Mcclmical (FIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
r6 -ro'1al
ess;
Check No. Check Amount: Cash Amount:
Project Cost: ❑Paid in Full 0 Outstanding Balance Due:
` �t9
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS -0/J-/7S
r;
License Number Expiration Date
`•• � Name of CSL Holder (f
II I List CSL'fype(see below)
y awr�Vrl _t/NQ Rd. Type Description .
No. ;md Street
U Unrestricted(Buildings tip-to 35,000 w. It.
TOFF�/e�d M Q l 9 S 3 R Restricted 1&2 Fitmily Dwelling
City/rown,State,ZIP M Masomy
RC Roaring Covering
WS Window and Sidins
SF Solid Fuel Burning Appliances
q75f_6v�I_ 1 Insulation
Tcle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) YQ �a 3
Ra }>,M7 12 J HIC Registration Number Expiration Date
I IIC Company Name or and HIC Registrant Name
i
No. Street� Email address
TVy95%Ct•e 1,l/0 r 0/4L ? 1t7f•0 6SE/
Ci /Town State ZIP Telephone
SECTION 6:WORKERS,.CorIPENSATION 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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........tp�' No........... O
SECTION 7a:OWNER AUTHORIZATION TO OF COMPLETED W HEM'
OWNER'S AGENT OR CONTRACTORALIES FORI PP BUILDING PERMIT
I,as Owner of the subject property,hereby authorize I�D f7 e,�T 17v `2
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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 this application is true and accurate to the best of my knowledge and understanding.
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 Contrnctor(HIC)Program);will no have access to the arbitration
program or guaranty, fund under M.G.L.c. I42A.Othc7impormrrt in-fbrrn-ati6-n on"the HIC-Program can be tot' t—lm
%vw.v mass.wWoca Information on the Construction Supervisor License can be found at www.ntass.uov.!Jns .
2. When substantial work is planned,provide the information below:
"rota) floor area(sq. R.) N ,(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
Type ofcoolingsystem Enclosed- Open
). "I'wal Project Square Footage'may be substituted for"rota) Project Cost"