4B HALSEY WAY - BUILDING INSPECTION The Commonwealth of Massachusetts
�\ Board of Building Regulations and Standards RM
e %It'N'ICIP.\1.1'I.1"
Massachusetts State Building Code. 780 CMR. 7,i, edition IS I: j
Building Permit Application To COnsuttct. Repair. Renovate Or Demolish a Krri,rJ./inwiu,
One- or Ttru-Fumih, Dtrellin,q 00S
This Section For Official Use Only I
—
Building Permit N nber: D:ae Applied: S
Sienature: —
d d CUlitml)Flonel'/ Vspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pr�t perty :>ddress: 1.2 Assessors Map & Parcel Numbers
I.la Is this an accepted street? ye — ✓ nu_ Map Nunther Parcel Nmnher
13 Zoning Information: 1.4 Property Dimensions:
"Zoning District Proposed Use Lot Area(sq It) Frontage(it)
1.5 Building Setbacks (ft3
h— Front Yard Side Yards Rear Yard
i
Required Provided Required Provided Required PnwiJrJ
I
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public ❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow et of Record:
Name (Print) .Address for Service:
4-?8 -
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration($) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': /n O E e02L/4—cif W — -
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ /D600 I. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost (Item 6) x multiplier x
i
3. Plumbing $ 2. Other Fees: $ —
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ j
Suppression) Total All Fees: S
Check No. Check Amount: Cash Annxnrt:
6. Total Project Cost: $
1600 0 Paid In Full 0 Outstanding Balance Due:______
SECTION 5: CONSTRUCTION SERVICES
5.1Licensed Construction Supervisor (CSL)
CAI-M/jee j 17 U6S &ROidential
;&i
F.v piratiuu Dale
Name of CSL- Ili cr
PA[ /� MQ O� w)�— Descripion
op to li,W0 Co. Ft.i
stricted ISC'_ Famile Dk%elline
Sthgnau re sonry Only
47-& n ��d� sidemia' Roo tin�Cosenne_
Telephone sidential \Vmdom;md Stdmy, _
sidential Solid Fuel Ifurnme :\ ilrm.r In>I,ill:niou
sidential Demolition
5.2 Registered home Improvement Contractor (HIC)
HIC Company Name or HIC Registrant Name Registration Number----
i
Address
Expiation Date
S;",_p_�rr 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 ptoc ode 1
l this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... ❑ No ........... O I
O,ECT1ON 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN 1
WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owrtr of the subject property her
authorize _ ___._. __ to ac[on my be had f. in all ;natters
relative to work acthorizad by this building permit applwafion.
Signature of Owner Date
SECTION 7b: OWNER[ OR AUTHORIZED AGENT DECLARATION _
I, ee41 6:: M/J rig 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 1.00
Signature of O ner Authorized Agent Date
(Signed under the wins and penalties of egg )
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 730 CMR Regulations I IO.R6 and 1 IO.RS, respectively.
'. When substantial work is planned, provide the information below'
Total floors area (Sq. FL) (including garage, finished basement/attics, decks or porcht..
Gross living area lSq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system .`lumber of decks/ porches i
Fype of cooling SyStem Enclosed Open -- -----
3. "Total Project Square Footage" may be substituted fir "Total Project Cost"