2 HART - BUILDING INSPECTION (2) The Commonwealth of Massachusetts RECE VEQ
Board of Building Regulations and Standards tSP ECT
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Massachusetts State Building Code,780 CMR
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Building Permit Application To Construct, Repair,Renovate Or 13%o1A/�4sri 9 A_I� S
Oire-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Apped:
1 Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Plerty Qd1deres: 1.2 Assessors Map &Parcel Numbers
1.1 a Is this an accepted street?yes O�no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWN RSHIP'
wn �rofRec I D h � h� f�
N me(Print a City,State,ZIP P
WeiA C,cmn IMS 1��14
No.and Street _Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply)
Nev Construct on❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration( dition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
d ..
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 11� i 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: i
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $/Grp DDD ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5 Co st //ajjction Supervis cense(CSL)
��� gn V'UJ� icense Number Expira[io Dale
amz of CSL Holder G _
l MM t�a, p�J List CSL Type(see below)
o.a Street ;1d
[ ���1,'J /�.� Type Description
/_�/� U Unrestricted(Buildin s n to 35,000 eu.ft.41d v� R Restricted 1&2 Family Dwelling
Grty/101111, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
Q SF Solid Fuel Burning Appliances
O I Insulation
Telephone Email address D Demolition
5..2��R�eggisteredd.Home Il p,,ro�ve��y(,e�nt Contractor(HIC)• C/ _ Y �
V W N l t/h&-77 N C �m HIC Registration Number Expiration Date
Co pany anme or C Regi ant N 1,t}�'�/1 I �I/�� /1/{yn
NWo. Side ^LI/�/� Email address
Ci / wn, State, Telephone
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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.
Print Owner's Name(Elecnunic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
co tainted in application iMA11
d accurate to the best of my knowledge and understanding.
1 f xl
Pri t Owner's or Authorized Agent's Nkme(El onic 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.rilass.gov/dus
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"