38 HARBOR ST - BUILDING INSPECTION (2) d 84962
4 9 62
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ThA14e Commonwealth of Massachusetts CITY OF
W
Board of building Regulations and Standards SALEIvI
00 Massachusetts State Building Code, 780 CMR Revised.Nar2011
� Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
(! This Section For Official Use Only '
Building Permit Number. led.,
CD -building Ot7icial(Print Name) signattao; - Date rn
1 SECTION 1:SITE INFORMATION` r^ -cl�+� '
111 1.1 P opert y Ad ress, y ±1.4
essors Ninp&Parcel Numbers
N �t7r-9d - J.T._ r—
I.1 a Is this an accepted street9 yes nomber Parcel Number rr j b
1.3 Zoning Information: perty Dimensions: vZoning District - Proposed Use (sy R) - Frontage(It) ,p
ci
1.5 Building Setbacks(D)
Front Yard Side Yards - Rear Yard
Required Provided :Required - Provided. Required ProviJed-
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal O On site dis sal system ❑
Public❑ Private❑. .. — Check if es❑ pO y
SECTION2: PROPERTY OWNEMAW;
a�,me(Print),
rt of Record�r/YJt j7 Q L C^Q �e�✓/ �A
/ �// Ci/[) State.ZIP /rq/ oZ Mar i [�pyYl
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg.❑ NumberofUnits_ I Other ❑ Specify:
Brief Description of Proposed Work': ,a a o 0
r L fl
/— G
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item - Estimated Costs: Official Use Only
Labor and Materials
I, Building $ I. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S QU • r� ❑Standard City Application Fee
❑Total Project Costs(item 6)x multiplier x
�^ J. Plumbing S 3 �d� c7v ? QtherFees: $
\ 4. Mechanical (HVAC) S List:
5. Mechanical (Fire 5 'total All Fees:S
rf"ro'U1
ession)
Check No. Check Amount: Cash Amount:
Project Cost: S� .. ❑Paid in Full 0 Outstanding Balance Due:
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name ofCSL Holder
List CSL'fype(see below)
TYPe'- - Description
a.and Street
U Unrestricted(Building!tip-to 35,000 cu. ft.
R Restricted !&2 Famil Dwellin
City/town,State,ZIP M Masonry
_ RC Floating Coverin
WS Window Sidinit
SF - Solid Fuel Burning Appliances
GJ
. 1;> 1 Insulation
h r
f'?�t Tcic hmte Email address D I Demolition
yy
t� 5.2i1tcgistered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
_ Cv7
No.&M Street - Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS',CONIPENSATION INSURANCE AFFIDAVIT(M.O.L e.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...........0
SECTION7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEN::_
OWNER'S AGENT OR CONTRA CTOR•APPLIE3 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
SECTION 7b:OWNER!OR AUTHORIZED AGENT DECLARATION
By entering my name below,)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.
Pr Owner's or Au o tzcd Agent's Nmt ccuonic Signature) Date
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 1W have access to the arbitration
-- —•-- --
program or guaranty fund under M.G.L.c. Id2A.Other Important inToirnation""onlhe NICYmgram can a loon t
www mass cov:'oca Information on the Construction Supervisor License can be found at ytAA m ss.uovl .
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) N (including garage, finished basementlattics,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 orcooling system Enclosed- Open
3. 'Total Project Square Footage"may be substituted for"'focal Project Cost"