58 FELT ST - BUILDING PERMIT APP $ 12 b Cr— S 7-qV7
The Commonwealth of Massachusetts
r '_ Board of Building Regulations and Standards CI Y OF
Massachusetts State Building Code, 780 CMR -201b SUN 13 ��� tM
(v i Revised Agar 2011
1 Building Permit Application To Construct, Repair, Renovate Or Demolish a
(� One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A 'ed:040,00 / /
6 /� l
' Building Official(Print Name) Signature Date
�fl SECTION l: SITE INFORMATION
1.1 Proper ddress: 1.2 Assessors Map& Parcel Numbers
sN
I.I 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 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.40. §54) 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 Oyvnerlt'of Reco-rd: ^ r O/Q,D
n 1�(a,lAe
Name(Print) Cit ,State,ZIP
No a d Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building Owner-Occupied IiKRepairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work : ZA&W Q1 w t/I S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
❑Total Project Costa (item 6)x multiplier x
3.Plumbing S 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 18 b ❑Paid in Full ❑ Outstanding Balance Due:
1M (a t L Ln --A� (21,C
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License-(CSL.) If Ct� (_,}C,, —
\'� ',�C�\V\ Lionce i`on n.- \ LaIltravon Dale
Name of CSL Holder 'J
List CSL T�Tc(.cc beiow) l
Tvpt Description
i
�t 0316�1 - 1
i '7 UriTeSlT]oeC(B-Uildv gS up to�5.000 cu-f.)
r 1V,J� �2r,,x, Use4 1 R Restricted 7A',2 F Fanny Dwelhn
Ci y/Town,State.ZIP n M Masonry
RC Rocf l Covering
WS Mlindow=and Siding
Sl- Solid Fuel Burning Appliances
l Insulation
Tel hone Email address D Demo7iticn
{5.2 Registered Home Improvement Contractor (HIC
�E0-n �ll V Si: ( ) HIC Registration Number Expiration Date
1JIC Company Name or IBC Registrant Name
Jks -S oc-\ Of.
Nu und Street
9 =-.�SSU "C?1SSo Email address
Ci flown. State, L Telephone
SECTION 6-WOiiKERS'COMPENSATION INSURANCE AFFIDAVIT(NI.G.L c'252:§25G(6)j
WoTkeT<_Cempensatien Insursmce affidavit mu<_t be completed and submitted with this_application. Failure to provide
Us affidavit will result in file demo] of the Issuance c the building permit..
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIESS FOR BUILDING PERNUT
1,as Owner of the subject propery,hereby v authorize T -N _A<\`\
to act on my behalf, in all matters relative to work authorized by this building permit application.
d111 U
Print Owner's Name(Electronic Signature) Date
SECTI N 7bi NEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, her by a est under the pains and penalties of perjury that all of the information
contained in this appli tion s tm and urate to the best of my knowledge and understanding.
°13
Print Owner's or Authorized ut's N (Electronic Signature) Date -
_
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. ov/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 halflbaths
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"