17 FLINT ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts EIVED
URI'
Board of Building Regulations and Standards ,.Massachusetts State Building Code,780 CMR, 7'"edition T VICES
USE
— Building Permit Application To Construct,Repair,Renovate Or Demolish a . Ui ► °�1 5
One-or Two-Family Dwelling `�
This Section For Official Use Only
Building Permit Number: '"' 9*' Date Applied: .. . t'
�— Signature
Building Commissioner/inspector of Buildings Date -
SECTION-1:SITE INFORMATION
1.1 Property Ad sg� / 1.2 Assessors Map&Parcel Numbers
l.l a Is this an/accepptteed street?yes/T no Map Number Parcel Number
1
1 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 El Private❑ Zone: _ \ Outside Flood Zone? c. .Municipal❑ On site disposal system El Cheekif es❑ .o ;
SECTION2: PROPERTY OWNERSHIP'
2.l Owner'of Record:
TaxC�sei ,JRLCE (,IOaliL^'w/ 7 //) /
Name(Print) Address for Service: :a
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)'
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ FAddition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work 2: o yeti bO
v r uo
t . Fe C. e2 el
SECTION 4:ESTI ATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
Labor and Materials y "
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 $ 2.=Other Fees: $ - -
4. Mechanical (ITVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees: $
/' Check No Check Amount: Cash Amount:
6.Total Project Cost: $ 7 Swi ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) y /
License Number ExpirAmif Date
Name of CSL-Holder
List CSL Type(see below) V
Addre Type Description _.
ss
U Unrestricted(up to 35,000 Cu.F[.
R Restricted 1&2 Family Dwelling
Signature (' M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re red .op e lmprg /11 C)QenTC o`ontract _(}II cs�
L/ y toy UFO
HIC Com an Name or HIC Re istrant Na�}} ``II J Registration
/Number
/
P Y g Address LL
Expiration Date
Signature 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 .......... ❑ No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN,
R'
OWNER'S AGENT
/O�RCONTRACTOR APPLIES FOR BUILDING PERMIT
I, / 1 411/ v/-,S r v- as Owner of-the subject property hereby
-- authorize CZ „ _ '�e� -to act on my behalf,in all matters
relative to work authorized by thi, bui 'ng permit application:.. .
Signature of Owner Date
SECTION 77b: OWNERS-OR AUTHORIZED'AGENT DECLARATION
I, // S- /Z /�C/L a C/ J/ Gck—, ,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.
Print Na
Lam'- S
Signature o Owner or Aut oriz Agent Date
(Signed under the pains and-penalties of perjury
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(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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 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 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"