9D GRISWOLD DR - BUILDING INSPECTION The Commonwealth of Massachusetts
LBudding
Board of Building Regulations and Standardsl OR
Massachusetts State Building Code. 780 CMR. 7'"editionFBuilding Permit Application To Construct. Repair. Renovate Or DemoliishonmutOne- urTtru-FamilrDtir!ling "�This Section Fur Official Use Onlmit Number: Date Applied: a�
Signature:
Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
E
ddress: 1.2 Assessors Mup & Parcel Numbers
�' ti?/ccepted street?yes_ no Map Number Parcel Number
formation: 1.4 Property Dimensions:
Proposed Use Lot Area(sq A) Frontage Ui)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
7wperl
Provided Required Provided Require) Pruv Wed
[2.1
(M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
❑ Check if es0 Municipal ❑ On site disposal sysrcm ❑
SECTION 2: PROPERTY OWNERSHIP'
rd 'e7M q(� �t?i5 wo/d
Name(PnnW Address for Service:
G32 S
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building S 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
?. Electrical S ❑Total Project Cost(item 6) x multiplier x
3. Plumbing 5 1 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S
Su ression) Total All Fees: S
Check No. Check Amount Cash Amount:
6. Total Project Cost: S ❑ Paid in Full ❑ Outstanding Balance Due:
I 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number E.xtuium n Date
Nanx otftc-`fi ey UY
4074 List CSL Type(ser below)
p Q Box T Dexri oun
Address eabody,MA UIVOU U I Unresincted to to 35'000 Cu. Ft.I
oil _ R RrstrictcJ IAt? Fanul y Dwelhn
Si nawre M On Mawn l
RC Residrnual Rr ofn Co%crm
Telephone WS Residenual Wmdm% and Siding
SF Roidentul Solid Fucl Ilunnna A 'liars In.i.JLuan
D Resrdemial Denwhuun
5.2 Registered Home Improvement Contractor(HIC)
Registration Number
HIC Company Nairx or HIC Registrant Name
Address Eapfration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. S 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure it, provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... I] No .......... 0
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.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I , 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 Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of per'u )
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 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 110.116 and 110.115. respectively.
When substantial work is planned, provide the information below:
Total floors area ISq. Ft.) (including garage, finished busement/attics. decks or porch)
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms j
Number of bathrooms Number of half/baths j
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
d. 'Total Project Square Footage- may be substituted for Total Project Cost"