88 A FEDERAL ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code. 780 CMR, 7ih edition MUNI LI �Lfll'E
1.
Building Permit Application To Construct, Repair, Renovate Or Demolish a Rrri.rcd Jun au,
One- or Tn o-Familv Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature: —
/B J' Commissioned Ins actor of Buildings Date
O SECTION 1: SITE INFORMATION
\ 1.1 Property stir 1.2 Assessors Map & Parcel Numbers
L la Is this an accepted street? yes_ no Map Number Parcel Numtx:r
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(I'll
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.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p �' y
gc ¢ SECTION 2: PROPERTY OWNERSHIP' �(2.1 Owner��gc„
V1 t
Name(Print) Address for Service:
S �e fi 1 My
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
1. Building $ ®r 1. Building Permit Fee: $ Indicate how tee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: C
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount Cash Amount
6. Total Project Cost: $ Q10fO �— ❑Paid in Full ❑ Outstanding Balance Due:
.11&V A �����
a
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL- Holder List CSL Type(see hlow)
Type I Description
Address U Unrestricted(up to 35.000Cu. Ft.)
R Restricted 1&2 Family Dwellin
Signature M Masonry Only
RC Residential Rouring Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burnm A chance Ilbl.dlatupl
D Residential Demolition
5.2 Registered 1 roves Cont or(HIC) 12! l�
HIC C N- or HIC Reg s N Registration Puiyber
Ad ress / r
Expiratich 4te
St n re 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 f 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
1, �2�q�1[�((� 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
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, -o— , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
*behalfner or Authorized Agent Date
e pains and penalties of perjury)
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 fLal 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 110.116 and 110.115, respectively.
2. When substantial work is planned.provide the information below:
Total floors 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"
— )I