17-21 FARRELL CT - BUILDING INSPECTION I3 -
y - 134 �q20 & . .
e Commonwealth of Massachusetts �tECE1VE
Boaz of Building Regulations and Standards OF
Mass chusetts State Building Code,780 CMIHSPECTIONAI ERVEIt4
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate 1r ep1plish6 � Oq
One-or Two-Family Dwelling ll�q ��UUbb o
This Section For Official Use Only
Building Permit Number:I. Date Appli .
Building Official(Print Name) Signature Date _
SECTION 1:SITE INFORMATION
1.1 Property Ad ress: ,b 1.2 Assessors Map&Parcel Numbers
L l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information) 1.4 Property Dimensions:
Zoning District Proposed Us Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(f)
Front Yard I I Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G .c.40,§ 4) 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 Qwne t of Record / A1,4 O,p,7 Q
Name(Print) / (II City,State,ZIP
("A C, ✓Y-G✓ •-1�
No.and Street I Telephone Email Address
SECTION 3: ESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing B filding❑ Owner-Occupied ❑ Repairs(s) ❑ eration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify:
Brief Description of Pro sed Wo k2:
_ Y
I, SECTION 4:ESTIMATED e6NSTRUCTION COSTS .
Item I Estimated Costs: Official Use Only -
Labo and Materials
1.Building $ I i 1 Building Permit Fee:$ Indicate how fee is determined:
2.Electrical I $ .❑Standard City/Town Application Fee r
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing I $ 2. Other Fees: $ �js}t
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Su ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
(sem-t 31 Z-i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder Eric W.Palm
Hilton Stmt List CSL Type(see below) (�
No.and Street S! laid MA 01970 Type - Description
U Unrestricted uildin s u to 35,000 cu.ft.
Ciwte,Z R Restricted 1&2 Famil Dwellin
M Maso
RC Roofin Coverin
WS Window and Sidin
'lk •- N 41 SF Solid Fuel Burning Appliances
Tele hone I Insulation
Email address D Demolition
5.2 Registered Homei Improv meat Contractor(HIC)
�LI�O�r'l l l<v
HIC Company Name or :tC e i HIC Registration Number Expiration Date
No.and.Stmct Avenue
g, p197Q
If(,� Email address
Ci /Town,Slate,ZIP Telephone
SECTION 6:WORKER 'COMPENSATION-INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurame affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the de iial of the lssuaniworf the building permit.
Signed Affidavit Attached? es No...........❑
SE TION 7 :OWNER AUTHORIZATION TORE COMPLETED WHEN
O R'S A( ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subj ct proper ,hereby authorize Er G
to act on my behalf,in;ill matte relative to work authorized by this building permit application.
Print Owner's Name lei is Si ature)
Date
SECTION b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name b I low,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is a and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent' Name(Electronic Signature) �/� /
Date
NOTES:
t. An Owner who obtains a bui ding permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home I nprovement Contractor(IUC)Program),will not have access to the arbitration
program or guaranfund un er M.G.L.c. 142A.Other important information on the HIC Program can be found at
o
www.mass. ov/oca Informal on on the Construction Supervisor License can be found at www.mass.-gov/dl)s
2. When substantial work is pl ed,provide the information below:
Total floor area(sq.R) (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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