20 HANSON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards
\ y? ' Massachusetts State Building Code, 780 CMR, 7"edition A
t
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling Ext 118
This Section For Official Use Only
(� Building Permit Number: _ Date Applied:
Signature: ,,-/,,
Building Commissioner/In ector of Buildings Date
SECTION I: SITE INFORMATION
1.1 Property Address:(.1 1.2 Assessors Map& Parcel Nu bers
oZb �CLnJnh Ji � �.—
I.is Is this an accepted street? ves — no__ Map Numbar Parcel Nember
--t -----
1.3 ':aping [rt,r ormat:cu: 1.4 1.4 r^roperty Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(fit)
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:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal P3 0n site disposal system ❑
I _ SECTION 2: PROPERTY OWNERSHIP`
2.1 O/w.(nert of Record: // / e ,I
,Ay � sf�Joyl - �D f Xri an (� Alem, ./�iy _
e_f rant) Address for Scrvice:
t e Telephone
SECTION 3:DESCRIPTION OF PROPOSED ORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':_ -
r s.
kh ILA,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
I Labor and Materi-als
r22.
Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x—,f-
3. Plumbing $ 2. Other Fees: $ I '
4. Mechanical (HVAC) $ List
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due:
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL. Holder List CSL Type(see below)
Type Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonil Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number _
Address —
Expiration mate
Signature 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 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:
NER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, � q�'G � t� A (/ .yJDYy as Owner of the subject property hereby
authorize_f C,h n to act on my behalf, in all matters
;;w
rized by this building permit application.
L Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,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
Si ned under the pains and penalties of edu
NOTES:
1. 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 trot 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 I IO.R6 and 1 IO.RS, 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
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 for"Total Project Cost"