73 FLINT ST - BUILDING JACKET 2� u� 3 j 1-
RECEIVED
The Commonwealth of Massachusetts I
=Buillding
rd of Buifdins Regulations and Standards C[TY OF i
sachusetts State Building Code, 780 C[IR 201b MAR 1 ��
evesed, /ar 2011
plication To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
n This Section For Official Use Only
•..Y Building Permit Number: Date Applied:
(�I�t Building Official(Print Name) Signature Aat)
t' SECTION 1: SITE INFORMATION
[" 1.1 Proper Address: 1.2 Assessors Nlap& Parcel Numbers
1.1a 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 In Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
L6 Water Supply: (bLG.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of ecord:
0 1 '' —1 6
Name(Print) City, State,ZIP
—73
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-: yt a ) ' y"t,L�j/p-�y - n
G. ti� S rW t i Onf
�Da as
SECTION 4: ESTIMATED CONSTRUCTION COSTS
[tem Estimated Costs:
(Labor and[Materials) Official Use Only
I. Building $ �(R L Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $..
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑ Paid in Full ❑ Outstanding Balance Due:
(Y\AtL>✓D 3 tl—(
SECTION 5: CONSTRUCTION SERVICES
7 :5 '
upervisor License(CSL)
6S «l4� ¢
License Number Expiration Date
' 1 List CSL Type(see below)
No. and Street Type Description
0ATU Unrestricted(Buildings u to 35,000 cu. ft.)
R Restricted 1&_Familv Dwelling
C y/Town, State, ZIP NI Mason
ry
RC Roofing Covering
WS Window and Siding
�> SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
)k+ ys!—�VI- � III
s inc - Loy log 9 la 2(-C Registration Number Expiration Date
HIC Company Namz or HIC Registrant Name
// S AI o ,l-t-� S+
No nd Street Email address
City/Town, State, ZIP 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 .......... 2 No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize GI y S -o✓2
to act on my b half, in all matters relative to work authorized by this building pernfit application.
16
Print Owner's Name(Electronic Signature) AR 1 e
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By erMring my name below, I hereby attest under the pains and penalties of perjury that all of the information
tort ' d this a INication is true and accurate to the best of my knowledge and understanding.
IT
Print Owner's or Authorized gent's Name(Electronic Signature) a
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 can be found at
www.mass.gov/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 basemenUattics,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"