13 FILLMORE - BUILDING PERMIT APP 1 -7
The Commonwealth of Massachusetts CITY OF
..
Board of Building Regulations and Standards' iECOt EgAF'� M Massachusetts State Building Code,780 CMR 'N SP"TIONQ R01s fat is 70I1
Building Permit Application To Construct,Repair,;Renovate Or WWI
One-or Two-Family Dwelling �Y�'��� 19 A 0 51
This Section For Official Use Only
(.� Building Permit Number: Date Applied:
t
Building Official(Print Name) Signature Date
l SECTION 1: SITE INFORMATION
1.11 gertyi
r�ss: 1.2 Assessors Map&Parcel Numbers
J rnof
l.la 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 Owne ofRnerel Mk--
City,State,ZIP
No. and Street .Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration( Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
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 Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: ' �•(j (N
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $/�ji3O b01 0 Paid in Full ❑ Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 tCon'trytty<io�upervis r nse(CSL)
/ `, ///G J�� J �cense Number) V ' Expiration Date
N me of CSL Holder
Yn rAw- r / List CSL Type(see below)
No.and tree[ Type Description
U Unrestricted(Buildings u to 35,000 cu. fr.
R Restricted I&2 Family Dwelling
C ty/ o n,State,zIP V M Masonry
RC Roofing Covering
WS Window and Siding
S SF Solid Fuel Burning Appliances
• S I Insulation
Telephone Email address D Demolition
5.2 RegisteredWomel rove ent Contractor(HIC) 1 �/_ J
( ( HI Registration Number Expiration Dale
pan ante or C Regi trant N
So e P . Oaf Email address
t / own, State;-ZIPd Telephone �D
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 .......... ❑ No...... ....
SECTION 7a: OWNER AUTHO RIZATIO TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER[OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in s application is true Apd accurate to the best of my knowledge and understanding.
14 b him &I
P4fit ner s or Authorized Agents Nkne(E onic Signature) Date
NOTES:
I. Ail 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.gov/oca Information on the lwonstruction Supervisor License can be found at www.mass.gov/dps
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 halfibaths
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"