17 HARRIS ST - BUILDING INSPECTION The Commonwealth of Massachusetts
CY�r Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CNIR SALRevised LE t nr2011
\,JJ Building Permit Application To Construct, Repair, Renovate Or Demolish a
f One-or Two-Family Dwelling
'[his SectioitFbrOfficial Use Onl -
Building Permit Number:, `Date Ap
Building Official(Print Name) r gna _ Date
SECTIOt L SITE I 07
Ll Propert Address: L2 Assessors Map& Parcel Numbers
1.1a 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.O.L c.40,§;4) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public� Private❑ Zone: _ Outside Flood Zone? Municipal eon site disposal system ❑
Check if yesC3
SECTION2, PROP.ERTB'OWNERSIID'i ;.
2.1 Owners of Re?
rd:
Name(Print) City,State,ZIP
l2 Alalrh's s,C 6glei'vt hIV
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPO5ED.WORKr'(check ail that apply)
New Construction Existing Building❑ I Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition III Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Propose NVo�c2•
�
SECTION 4: ESTIbL&TED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only..,
Labor and Materials
I. Building g I. Building Permit Fee:9 ` Indicate how fee is determined:
2. Electrical ❑Stanch<d.CityfCotvn•Application Fee
❑Total Project Costs.(Item.6)x multiplier x
3. Plumbing S 2. Other Fees: S
1. M-chanie,tl (IIVAC) S Lists
i. ,Mechanical (Fire J
Sii r ressium) _ $ Total All Fees:.S_
r, Total Project Cost: S Muck No.. Check Amount: ----Cash Amount
❑ Paid in Full ❑Outstanding ILlIallca I),,,;
r
,
SECTION 5: CONs-i-RucrION SERVICES
5.1 Cortstrucliott Supervisor Lll'cI1Se(CSL) �UDCt� _ /�31f 3
1 License Number Expiration Date
�DWar -
Name of CSL 1 Folder List CSL Type(see below)
�'rt k-ti Type Description
No a id Street U UnrestrictcJ DuilJin s u to Ji,000 cu. R.
I� � -3 �� (t Restricted ISt3 Funil Dwcllin
City/rown, late, GlP �I Ruotinr
- RC ootin Coverin
WS Window and Sidin,
SF Solid Fuel Burning Appliances
y� cox De
���P�yl { ,tf [ Insulation
` �// Ematl aJJrcss . _� D molition
l'cle hona
5.2,Registered Home Improvement Contra for(111C) 13��s
�e 111C Registration Number Expiration Date
I I 1. npappy N� ame or IIIC Re tstmnspf ung 6�j7,Fh
Email address
No.and S et
Ci /Town,State ZIP Tele hona
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.1 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 ..........0 No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COdD?LETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 3s Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Date
Print Owner's Name(Electronic Signature) -
SECTION 7b: OWNER' OR AUTHORIZED'AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that ail of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
u/ /yil wG r� Date
Print Owner's or Autlwrited:\gent's Name(Electronic Siguaturc)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Hones Improvement Contractor(HIC) Program),will rror have access to the arbitration
program or guaranty find under 1M.G.L. c. 142A. Other important information on the HIC Program can be found at
www nets:cur%aca Information on the Construction Supervisor License can be round at ttww.mas-',!I���dw'
2. When substantial work is planned,provide the information below:
_(including garage, finished basemcnVattics,docks or porch)
Total floor area(mi. R.) __—__ 1 rabitable room count _
Gros; living:vca(;y. d.l -- Number ofbedronms
Nuniberortireplaces...___--- — Nlitnbcroflt:tltI)MI's -__----
Nunthar
_--
I'cIlk:orllcming system - ----.._-- Fnclo;cd __.
()pcn _
�'�pe of an,ling ry;gem ---. -- --
t. I oi.il I'nga:[ '�yu.tic root.u,a" ❑ety he sub;board 6v