40 FELT ST - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts IRECBoard of Building Regulations and Standards IHSPECI EFIMassachusetts State Building Code, 780 CMR d,Nnr 2011
Building Permit Application To Construct, Repair, Renovate Or gSnoQ 56
One-or Two-Family Dwelling
This Section For Official Use Only
(J) Building Permit Number: Da Applied:
/o COI iK
Building 011icial(Pont Name). - ; Signature - Date
SECTION 1:SITE INFORNIATION
Lli Pro�perty yAAddre s: 1.2 Assessors hlap&Parcel Numbers
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Ili Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Reyuired Provided Required Provided
to 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 es❑
SECTION2: PROPERTY OWNERSHIP!'
2.1 Owner of Record:
car fsrr�� �1 77 a
,me(Print) .y ,y City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED\PORK'(check nil that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 13 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify: St✓e �i✓,s i �
Brief Description of Proposed Work': Sn'sYl�/ w %wg r✓co/aee .:�fce-Y
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials -
l. Building S $ O I. Building Permit Fee:$ _ Indicate how fee is determined:
❑Standard City/fown Application Fee
2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S P Qther Fees! S
q. Mechanical (FIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S 2 i 0 ❑Paid in Full ❑Outstanding Balance Due:
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Coitstructimt Supervisor License(CSL) 10 s/S 9 /, / 7
�.�� License Number Expu tm Dare
Name of CSL Holder List CSL'rype(see below)
SZ /l,le-44 d f1 -Type -- - Description .
No. and Street
—f U Unrestricted(Buildin2 tip-to 35,000 cu. 11.
<a/ri , 4 21 of [b — R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 Insulation
Tcle hone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) �y�N7 q Z7 /
—TiiSti d✓A9�f HIC Registration Number sphruti n Date
IIIC Company Name or tI1C Registrant Nome
/CA .) Z
No. and Street Email address
rd/r /��
Cit /Town,State ZIP Telephone
SECTION 6:WORKERS'.CONIPENSATION INSURANCE AFFIDAVIT(M.G,L.C.02.$ 2$C(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 Isluance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATIONTO BE.CONIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby authorize_�>_✓��
t9 act on my behalf,in all matters relative to work aut orized by this building permit application.
/1s
Print Owner's Norte(Electronic Signature) Dale
SECTION 7b:OWNEW ORAUTHORIZED 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 Authorizednts Age Name(Electronic Signature) Dale
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 no 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
wvww.mass.goL v.!oca Information on the Construction Supervisor License can be found at w�v'dns
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. R.) `^ .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. it.) Habitable room count
Number of lireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type ofcoolingsystem Enclosed Open
3. "Total Project Square Footage"may be substituted 1'or"Toed Project Cost"