0007B GRISWOLD DRIVE - BPA- q .
a, A' PUBIAC PRO P1.R"['Y
DEPAR"L'N1.1_. l"1'
APPLICATION FOR PLAN EXAMINATION AND IIUILUING PERMIT
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWBLI_INC,S
IMPORTANT:Applicants must complete all items on this page
SITE INFORMATION
Location Name 7-8 C— rt e�df eI �k$uiidin
Property Address
Map#
Located in: Conservation AreaY/N Al Historic district Y/N fV
Use Groups
(check one)
Residential(3 or more Units) I
Type of improvement Residential (hotel/motel RI
(check one) Assembly(churches) Al _
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants,recreation) A3_
Alteration Business B_
Repair/Replacement Educational E_
Demolition_ Factory(moderate hazard) FI _
Move/Relocate Factory (low hazard) F'2_
Foundation Only high Flazard If_
Accessory Building Institutional (residential care) I I _
Other(describe) Institutional (incapacitated) 12_
Institutional (restrained) 13_
5 ^7, Mercantile :M
Storage(moderate hazard) S I _
Storage(low hazard) S2
OWNERSIBI' INFORMA1 H)N(Please type or Print Clearly)
OWNER Name MA4 Muc oL..
Address �- cwr s r�� UA fir_
Telephone
DESCRIPTION OF WORK'10 BE PERFORMED vv,,
_� Div G � S 'G rat LJL �lL
ESTIMATED CONSTRUCTION COST SIJv
CONTRACTOR INFORMATION
Name Ro ln� I L L, ersre e
Address 1— Cb Hat rJ L,J
Telephone 9-)S, S 72f- '/ / /- Z—
Construction Supervisor's Lic # GS l $ 3 86
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION t `
Name t�J
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION _
Residential est. cost x $7/$11000 +$5.00. 22, S�
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury( p DQ
Signed ZL' - 0
Date OK
4.
N �
The Commonwealth of Massachusetts FOR
sk Board of Building Regulations and Standards MUNICIP:V.II'Y
Building Code. 780 CMR, 71"edition
S State 11Sh
i+ • ssachusett B
Ma
Ro oed Aunum_c
�� Building Permit Application To Construct, Repair. Renovate Or Demolish a ? te)y
One- or Two-Furnily Dtyelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature.
Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: r 1.2 Assessors Mup & Parcel Numbers
Cyr c �rJ�
Ma Number Parcel Number
L la Is this an accepted street'?yes no.
P
1.3 Zoning Information: 1.4 Property Dimensions:
Lot Area(s 11) Frontage 01)
Zoning District Proposed Use - q
1.5 Building Setbacks(Pt)
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:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system El
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: l3 C21 s,w .l r
ne Ir Muv o► .
Name(Print) Address for Service:
Signature - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairsls) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/rown Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
List:
4. Mechanical (HVAC) $
5. Mechanical (Fire $ Total All Fees: $
Su ression)
C� Check No. Check Amount Cash Amount:
6. Total Project Cost: $ z, 5"QQ 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
(� / CS 183 f3G� !"1- a2 -b q '
l Dk, £7 J, L 4ea,crGcA, License Number Expiration Date
Name of CSL- Holder
1 R r4 Q x A CAJ� List CSL Type(see below) U
Addre,sas. T Description
D a l e, !`M sl tJ t 9 G U Unrestricted top jup to 15.000 Cw Ft.)
R Restricted 1&2 FamilyDa-ellin
Sign ore �9 _ M I Masonry Only
r "�"�'"•�_— /� RC Residential Roofing Covering
Telephone \VS
Residential Window and Siding
SF Residential Solid Fuel Bumm :\ ,bane.• Installauun
D Residential Denwbuon
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone '
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. $ 2SC(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
1, - w. r / f r rr ;,o , as Owner of the subject property hereby
authorize to act on my behalf, in all mutters
relative to work authorized by this building permit application.
Signature of Owner Date
y� r SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, /C f�� f Y J L`h n cr re t.W 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.
Prin N
Signature of Owner Authorized Agent Date
(Signed under the pains and penalties of perjury)
NOTES:
I. 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 Horne 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 110.116 and 110.115. 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 i
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cowling system Enclosed Open
3. "Total Project Square Footage" may be substituted for"Total Project Cost"