40 FELT ST - BUILDING PERMIT APP �t
`• The Commonwealth of Massachusetts r r}
! Board of Building Regulations and Standards oO, �¢EAEp.M
Massachusetts State Building Code, 780 CMR, 7u edi , PZevisedJanuary
Building Permit Application To Construct, Repair, Renovate QQ`�¢VE�Jish a 1, 2008
One- or Two-Fwnily Dwelling INSPECTIONAL SERVICES
This Section For Official Use Onl
`n Building Permit Number: Date Applied: .16 AUb 31
A & 2 0
Signature: �tCINXX
Building Commissioner/Inspectororl3uildines IIYYWJJ Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Pay-eel Numbers
_ 4/0 `e
I— 1.t a Is this an accepted street?yes no Map Number Parcel Number
ll 1.3 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(tt)
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:$Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner of Record:
Sca t r _y a DLO S-f
Name(Print) Address for Service:
�Q q-� 'i, -
Signatur Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) DV Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory.Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed%Vorkz: TA K E OLO L J A7 keCri try it e y�/Nfd SLlt e 0--/iC�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I_Building $ 1 a 000 • dU 1. Building Permit Fee:$ Indicate how fee is determined:
Electrical $�.
❑ Standard City/Town Application Fee
" ❑Total Project Costs (Item t)x multiplier x
3.Plumbing $ 2. Other Fees:
4. Mechanical (HVAC) $ List:
5_Mechanical (Fire $
Su ression Total All Fees $ a
Check No. Check Amount: Cash Amount:,
6.Total Project Cost: $ 1 a 1 000, 00 ❑Paid in Full _ 0 Outstanding Balance Due:.,.,
Y11ia��(J q I2. ab c�N�
• SECTION 5: CONSTRUCTION SERVICES
^' 5.1 Licensed Construction Supervisor(CSL)
`%OL- S h License Number Expiration Date
Name of CSL-Holder
List CSL Type(see below) (J
Via—@�C��`f Type Description
Address /A, U Unrestricted(up to 35.000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Sigr .,ure M Masonry Only
7 - `/ —Lo_ol RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation.
D Residential Demolition
5.2 Registered Ho a Improvement Contractor(HIC)
�l�6 ., l.J�a,/s h / y fr y 2 8
HIC Company Na a or HIC Registrant Nam Registration Number
�S M= sd Sf Sc
ATL/?�, 4 27 2oiS
e / _
�__�&?V tf�n0� Expiration Date
Soffature 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 of the building permit.
Signed Affidavit Attached? Yes ..........19 NO ........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR""CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 3 CO f + V va- as Owner of the subject property hereby
authorize V_o_h GeJLi 1�Sb to act on my behalf, in all matters
relative to108v
authorized by this building permit application.
Signature r Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
11 ci C• ks t7 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
behalf. _
\ JaA n (J4 J Ste;
Print Name
Signature Of caner or Authorized Agent Date
(Signed under the sins and cnalties of )
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(FBC)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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110:116 and 110.R5,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"