6 HARBOR VIEW TER - BUILDING INSPECTION The Commonwealth of Massachusetts
� Board of Building Regulations and Standards Town of
�� Massachusetts State Building Code, 780 CMR, 7"edition Building
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tiro-Family Dwelling
r.\ This Section For Official Use Only
—\�j Building Permit Number Date Applied:
tSBuilding
P�L
Budding Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
y d �� 1.2 Assessors Map& Parcel Numbers
an accepted street'?yes no Map Number Parcel Number
g Information: 1.4 Property Dimensions:
ct Proposed Use Lot Area(sq B) Frontage(B)g Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c. 40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O. Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 gwn r'of Rec d: v r ^
( / �/I toy �4YL T� Fuel �Q 1� fL �D(t— v
Name int) Address for Service:
Signature Telephone
Mscnp
ON 3: DESCRIPTION OF PROPOSED WORK](check all that apply)
isting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
cessory Bldg. ❑ Number of Units_ Other ❑ Specify:
osed Wo kr:
*f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building I S 1 I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: f \\
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S
Su Total All Fees: S
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S �� 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N4mr ut'CSL- Helder List CSL Type(see below)
x
Tv pe I Description
Address U Unrestricted up to 35.000 Cu. Ft.)
R Restricted ITO Family Dwelling
Signature M Masonry Only
RC Rcsidennal Roofin Covering
Telephone WS Rrsidrntial Window and Siding
SF Residential Solid Fuel Bunning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date i
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
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Ow r Date
C ON 71b.O tOR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the sta en 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
(Signed under the pains and penalties of perjury)
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 ag 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 1 I O.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenNattics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces .Number of bedrooms -
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
1. 'Total Project Square Footage"may he subslmuled for"Total Project Cosy'