7 HARMONY ST - BUILDING INSPECTION The Commonwealth tit INassaClrusetts - -
e\ Board UI 13lllldllig Regulations and Standaids I ( dt
., . 511N1/-II'.\I III
I NlassaChusrtts State 13uildine l'nJe. 7511 ('M1IR. Tl' edition
4 I �l
Building Permit Application To Construct. Repair. Renuaate Or Ihnulli>h :t R, J Lnnnu t I
One- or To„-fmoilr On dlin,q
O
phis Section For Official Use Only i
V' 1
Bulling Permit Numb D to pl ied:
Sian:uure:
Budding Cum nos S nalcl/ nspecwr tit BulldingS Dale
SECTION I: ' . INFORMATION — --L
ret.2 :assessors flap & Parcel Numbers/cepted streetve _ nuMap Mother PaILCI Xwnhrr
rmation: 1.4 Property Dimensions:
Proposed Use Lot Area(sq If) Frunmge 111) —_
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Reymred Prodded
I
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 ❑ On site disposal System ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 1 ( `�✓
Name (Print) n Address for Service
41 iG� T39-7L1) -
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (cheek all that apply)
New Construction CC] Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteraion(s) ❑ Addilimm ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specily:
Brief Description of Proposed Work': _
1\,JU ill ti
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(labor and Materials)
I. Building S � I. Building Permit Fee: .$ Indicate how fee a determoreJ:
❑Standard City/l own Application Fee
'_ Faectrieal S ❑ Total Project Cost' (Item 6) x multiplier x _
1. Plumbing S _'. Other Fees: S //�l
4. Mechanical IHVAC) S List:
5. !Mechanical (Fire y _--__"-----
Sit) rcumn) Total All Fees: S
I Check No. Check :\mount ('ash e tint
0 -- - ---i
Total Project Cost: Y � 0Paid In Full 0 OuutanJ tine Balance Due
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSI.) ---- — - ---- -__—
lice roe ,,V umber I\puall��n 11.ne
\anx• �d CSL IL.Wer I.1,1 CSL -I'%Ix I cc below I
\.1Jres> —�
l lnrr+trtelCJ In h) I00 Cu hLi
R Resumed 1F_1 Fanuls Dw:llule__ —�
SignaUue M \ta,onrn Onls
_ RC Ite,IJelttlal RoolSne Cov:rin,e_rrlephunr \\S Rca dermal \\'n1d.... .inJ
�SF Resideuu.d Solid fuel Bmnl - \ICI+I i.in.e Iu.i,J Lin�m y
D Re siJenl),II Deuwhlnnl
5.2 Registe um 1 Maw nt C Jdactor IIIIC)
I IC Col 'u r 'at • or IIIC egls(l t — —Rr�Islrau�unV�uiuQher�_.__j.__
lf�—CL/
OW7 Enpiramm D
Sign a ule Telephone !�'
SE ON 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (N1.G.I c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and ,uhollued with this application. Failure it, pros IJc
this affidavit will result in the denial tit 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
— as Owner ot'the subject property hereby
authorize _ __ _ _to act tin my hehalf. in all matters
re!utne to %vork authorized by this building permit application.
i
Signature of Owner Dale
SECTION 7b: OW'NEW OR AUTHORIZED AGENT DECLARATION
1• E-1--t'-�_�_. , 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.
Pont .Name
Signature of Own r or uthurized Agent Dale17
(Signed under tit• airo and enaltics of era 1
NOTES:
I. An Owner who obtains a building permit to do his/her own work. ur:m owner who hires an unreglsiered ,nnoa,7
(nut registered in the Home Improvement Contractor (HIC) Program), will not have access to the :rburaoon
program or guaranty fund under M.G.L. c. I42A. Other important infnrmotionon the MC Program and
Construction Supervisor Licensing (CSL) can be t(nlnd in 780 CMR Regulations I IO.R6 and 110.R5. respecrlsely.
1 When substantial work is planned, provide the Information below:
Total flours area!Sq. Ft.) tincluding garage. finished ba,enlent/aulcs. decks or porch)
Gros living area (Sq. Ft.) _ Habitable room count
Number tit tlreplaces :Number tit hedruoms
l Number tit hathnlonls Number of 11AI f/hal h, _--------- —___ _ _
fspe of heating syaem Number of Jccks/ porches
I \'pe of ,y,lem
1. "Total Project Siµ are Footage- may be substituted for 'Fowl Pmgect C•mt"