25 HANCOCK ST - BUILDING INSPECTION (4) KI 3 12
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mnr 201/
One- or Two-Fancily Dwelling
�Q This Section For Official Use Only
/J Building Permit Number: _ Dat Applied:
Building Official(Print Name) Signature �Le.�✓ �/a 1 /
rr SECTION 1: SITE INFORMATION
1.1 Property Address: r +
Imo, 1.2 Assessors Map& Parcel Numbers }
A tv
1.1 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(sq ft) Frontage(it)
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:
"Lone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
O ner'of Rero�Vie E ------ — �.-- �v_
Name(Print) Ciry.:[ate.LIP
No.and Street Telephone Finail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied-JZ— Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Awessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work": All
—._ _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 1. Building Permit Fee: $_— Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical 5 ❑Total Project Cosy(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees:
4. Mechanical (NVAC) $ List:
5. Mechanical (Fire $ —
Total All Fees:
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S / -.a0A7 ❑ paid in Full ❑ Outstanding Balance Due:
`rnla,L�o G_ C-
. colzl
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) .y
fi �i /� lP !✓P License Nu�,ber 5 Expiration on Date
Name ol'CSL Haldef
List CSL TyPc(see below)
No.and Stncei _ T ley.WI
Description
f /-7 1 L> z U ted(Buildin s u to 35.000 cu. 11.)City/Town.State,ZIP / — `^'R d 1&2 Family DwellinM RC CoverinWS end SidinSp el Burning Appliances______ _ _ n'fete hone Email address D on
5.2 It istered Home Improvement Contractor(HIC lt'z w,j /R A;1 FAA,Ne'S k �U� i.✓S— �_ Iucaeg.
HIC Cmnpany Name ar HIC Regisygmit Name islr'ahen Nmnber' li%pt'LLllml Date
No,/and�Street� --
�_A" f`l?l I-D Z/Cj 7 —. I:tnuil;address ——
City/Town,Stale,ZIP l f/1—^'� It / -'1'ele hunt
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 provide
this affidavit will result in the denial of the Issuuaanp-of the building permit.
Signed Affidavit Attached? Yes .......... [!r No ........... ❑
SECTION 7a:OWNER AUTHORIZATION TO RE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby au[horize9,Gi_J� Cf,! hid' 1.[9 — j, ✓;.'_I
to out oil my behalf,in all matters relative to work authorized by this building permit application.
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SECTION 7b:OWNER' Olt AUTHORIZED AGENT DECLARATION
By a itg'm tan below. I hereby attest under the pains and penalties of perjury that all of the infoniatiou
-cott)amed in this upp icalion is irue and accurate to the best of my knowledpc and understanding.
P,rinr Owner's ur Authorized Agent's Name(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 ltnprovement Cnnnztecor(1-IIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important In foil]moon ort the 1-11C Program call be found at
www mass.nov/oca lniornmtion on the Conso action Supervisor License can be found at wwwana.ss.uuy/dpri
2. When substantial work is planned,provide file information below: --
"fuwl !lour ai,ra(sq.ft.) r (including garaga, finished basement/attics,decks or porch)
Gross living area(sq.fl.)__ Habitable room count
Number of tireplaces Number of bedrooms
Numberofbathrootns —_ Number oflial'f/bat'hs
Type of heating system Number of(leeks/punches
'Type of cooling sysem _ Enclosed
3. "Total Project Square Footage" may be substituted For...1"otal Project Cost" _--