10 GABLES CIR - BUILDING PERMIT APP 1 The Commonwealth of Massachusetts
° Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR, 7`s edition NTUNICIPALITY
USE,
Building Permit Application To Construct,Repair, Renovate Or Demolish a RevisedJanuory '
One-or Two-Family Dwelling 1, 2008
This-Section For Official Use Only' -
Building Permit Number. Date Applied: /
Signature: lzl 4
Building Commissioner/Inspector o uildings Date
SECTION 1:SITE INFORMATION
1.1 Pro, r Address II 1.2 Assessors Map R Parcel Numbers
1"i� (mac �e5 Ct� SSIr 1 CACI
I.l 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(sgft) Frontage(fi)
1.5 Building5etbacics (ft)
Front Ynrd Side Yards Rear '
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'of Record-
�"W' Q- (�-'r U'V' b�.theSSc..� �,t'� o4to�e5 C 1' S�iLe. GIQ�O
Name(Print) Address for Service: .
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK (clink all that apply)'
,es C^nst,^ c lc:: ❑ Exist ui' yg❑ O::r Jccupicd ❑ , R.e.p3 s(s)''.G�' ':Ite�t cn(s} G'' : 'd C
Demolition ❑ AccessoryBldg. ❑ NumberoFllnits._._._ Other O
Brief Description of Proposed Work': a.§lJlti'c � hS w rv'�r(6 L N o' i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(labor and Materials)
1.Building $ l C( 3. 1. Building Permit Fee:$ Indicate how fee is determined:
30
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost; (Item 6)x multiplier x-
3.Plumbing $ p 2. Other Fees: $ "
4.Mechanical (HVAC) $ O List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S Lq, 3 3a 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS. CONS, CTION SEVgcEs
5-I Licensed Construction Supervisor(CSL) 4+ 51
License Number Expiration Date.
Name of CSL-Holder 1 G
)0 I i c ' S Sl Q y�b O✓U OLSi J List CSL Type(see below)
ddress T e - :'. . - Description
U Unrestricted(tip to 35,000 Cu.Ft.) '
Signature R Restricted 1&2Family Dwelling
U£�-4trt -09Sa. M. Masonry Only
RC Residential Roofing Covering
-
Telephone. WS Residential Window and Siding
" SF Residential Solid Fuel Burning Ao liance Installation
D Residential Demolition
5.2 Registered ome Improvement /olntr�actor(IiIC)
.(
HIC Company Name or HIC Registrant�t�§r�a Registration Number
S{.: "0,/ -� l LPO IWA- 61S3a
Ci .Ve SDb- �l�t'-oci9� Expiration Date
Signature Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFEDAYIT(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 Issuancp of the building permit
Signed"Affidavit Attached? Yes ........... No...........❑
SECTION lac OVSNEk i. UTHOR 7ATION T.0 BE COMPLETED FV�N:. . '
OWNrER'SAGENTOR:CONTRFCTORAPPLIES.FORBUIIL�DB Gam, RE T
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.
Signature of Owner - Date
n� -SECTION 7b.03TJNER':'ORAi3TH0RI EDA1 ENT,IIE;GLAR•AT?ON
} tSY1Q,nnl'c`: 4t11�.' a� 4oetnr: rtliorzedAtentttretyl�Itite
tiai tiie stateme sand ifonrv�tion"on Lte ; : eeiu� apptua[ion azetn e a id accurate, to the zst o my k io a]zd&e and
ri G,n l�P fA it i C uln
Pr t iJamc
Signature of Owner or A " a.ed Agent Date
(Signed under the ain 'es a 'u
NOTES:
l. 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 nor liave 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 I I O.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft). (including garage,finished basementlattics, decks or posh)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalffbaths
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"