12 FOWLER - BUILDING INSPECTION w
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I The Commonwealth of Massachusetts z
Board of Building Regulations and Standards CIT}.pF SA N
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Massachusetts State Building Code,780 CMR Revised 201
Building Permit Application To Construct,Repair,Renovate Or Demolish a 'y t�•t
One-or Two-Family Dwelling N m
This Section For Official Use Only z
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Building Permit Number: Date Applied:
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Building Official(Print Name) Signature_ D ' 40
SECTION 1: SITE INFORMATION
1.1 Proper t AFOre � P1 l T 1 1.2 Assessors Map&Parcel Numbers
Lla 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 Owner ofReco a rd:
Name(Print) City,State,ZIP
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No.and Street Telephone Email Address
SECTION 3:DESCRIPTI N OF PROPOSED WORIe(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: FLY Z1 t11A7�bA
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ j D 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
y ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total A0 Fees: $
Su ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ l c1i9 U ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES p G
5.1 Construueotinn Supervisor License(CSL) C Q 7Z7 A
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
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No.and Street T e Description
07 ; .,n U Unrestricted(Buildings u to 35,000 cu.ft.
KI Lt �t'U� Restricted 1&2 Family Dwelling
City/Town,State,ZIP / M Masonry
0 ( > RC Roofin Coverin -
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home
Improvement Contractor(HIC) llat�7z( * f HIC Registration Number Expiration Efate
HIC Company aoHI
Registrant Name II
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No.and Street `'r Mail addr�
City/Town,State,ZIP MIMF
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
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 this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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
Information on the Construction Supervisor License can be found at
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"maybe substituted for"Total Project Cost"
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Office✓of Consumer Affairs&B siuess Reguiehoa License or registration valid for individul use only
0 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registrat[on:,'m Type: Office of Consumer Affairs and Business Regulation
10 Park Mean-Suite 5170
Expiration: A12342014 DBA
On Boston,MA 02116
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FRED HOPPS A
15 WALCOTT RD.
BEVERLY MA 0191 Undersecretarynature
j 9VIGUFNG PERFORMANCE INSTITUTE, rNC.
107 H PAPAr Suite 310
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ssachusetts Department of public Safety
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