8 HAMILTON ST - BUILDING INSPECTION The Commonwealth of Massachuset ``d�p�sTa
OF
Board of Building Regulations aw I ds tvtMassachusetts State Building Code, 780 CnlVFII Ci ( r 2011
v Building Permit Application To Construct, Repair, I��v`gtor Dem
One-or Two-Family Dwelling
b, This Section For Official Use Only
—� Building Permit Number Date Applied
I
Building OlTicial(Print Name). - Signature... - Date
SECTION 1:SITE INFORMATION`
Prop rty lddress: 1.2 Assessors Slnp&Parcel Numbers
Ham .
1.1 a Is this an accepted street9 yes no Nlap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Laving District Proposed Use Lot Area(sq 11) Frontage(11)
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 cs❑
SECTION2: PROPERTYOWNERSHWP
Owner'of Record: r) l � e, o / 1 7a
/' ✓r K rt kt
ohm (Print) 11 rr City,State,ZIP
8 H& NA "1 u`^ 5T .
No.and Street Telephone Email Address
SECTIO J• ESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building EqOwner-Occupied Erf Repairs(s) ❑ Alteration(s) ❑ 1 Addition Cl
Demolition ❑ 1 Accessory Bldg.❑ I Number of Units_ I Other ❑ Specify:
Brief Description of Proposed\York': � wM ,I= au ✓e-Pill ✓ec+ ✓
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building s ` py}j � 1. Building Permit Fee:S Indicate how fee is determined:
❑Slandard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S ,�therFees: S
q. Mechanical (HVAC) S List•
5. Mechanical (Fire S Su ression) 'fatal All Fees:5
,v Check No. Check Amount: Cash Amount:_
6. Total Project Cost: .S Ur 00 0 Paid in Fu11 0 Outstanding Balance Due:
l
SECTION 5: CONSTRUCTION SERVICES S
r
5. Construction Supervisor License(CSL) GS _071 3-2 7 1 -Z 3 • / ' +
S 'U.) e u✓e y License Number Expiration Date
Name of CS'L- `Holder List CSL Type(see below)
2 Type - Description
No. and Street
A U Unrestricted(Buildinlis.up to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Etyfrown,State,ZIP hl Masonry
RC Rooting Covering
wS Window and Siding
SF Solid Fuel Burning Appliances
7f3 1 Insulation
Telephone Email"add ess D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date '
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP TAe hone
SECTIO 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25CM).
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isfuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SEC TIO 7a WNEl2
S AGENAUTHOR12AT10N:TOBECOMPLETEDWHEN i'
OWNER' T OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTIOt 7b:OWNEW 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.
/- g-,.c) e--O� /z - i s- i y
Print Owner's or Authorized Agent amc(Electronic Signature) Date
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 Lug have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
xa%vw.nmss.,•ov'oca Information on the Construction Supervisor License can be found at wwa.mass. ov'JL
2 When substantial work is planned,provide the information below:
'total floor area(sq. R.) �'� .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room count -
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'type of heating system Number of decks/porches
Type of cooling system Enclosed Open_
3. "Total Project Square Footage"may be substituted tbr'"rotal Project Cost"