33 FAIRVIEW RD - BUILDING PERMIT APP The Commonwealth of Massachusetts
° Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR t �V War
p�1 Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
pl V V One-or Two-Family Dwelling O1b OCT 12 A I I: 3 j
4r/1$i This Section ForOfficial Use Only
yV1 Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
3 3�4�" / 0(�.i A-b
1.1a Is this an accepted street? yes_ no Map Number Parcel Number
1 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.4o,4 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal stem ❑
Public❑ Private❑ Check if yes[] P Y
Y
SECTION 2: PROPERTY OWNERSHH''
2.1 Owner'of Re ord:
Name(Print) ' City,State,ZIP
3-z / ,4 T 2& 3/-?• P.& 67
No.an Stree�t Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupie Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building $ 6l y>p. 1. Building Permit Fee: $ Indicate how fee is.determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
0042, Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License 1 umber Expiration ate
Naffie of CSL Holder '
�, n List CSL Type(see below)
No.and Street /Y T e Description
Unrestricted(Buildings u2 to 35,000 cu.ft.
lCt—ty'/Town,Stale,ZIP .1 - Restricted 1&2 Family Dwelling
M Mason
RC Roofing Covering
WS Window and Siding
p p/� t/ SF .Solid Fuel Burning Appliances
1 )9 - O 2- 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) )� �.L 19
AA
Ag� A.Ag � M` y' ' HIC Registration Number Expiration Date
Company Name or HIC Re 'strant ame �,
Pro.and Strut Email address
Ci /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 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
L
I,as Owner of the subject property,hereby authorize
b
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Eleelronic Sign ure) Mate
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
co tain is ap i is tru d accurate to the best of my knowledge and understanding.
P int 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.L. 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.gov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"