2-A HART WAY - BUILDING INSPECTION m
The ('onmwnwcalth of Massachusetts
i Board of Building Regulations and Stanch ds H)R
A {Y' ;�a Massachusetts State Building Code. 780 C•MR, 7 edition 1;SL
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Building Permit Application To C'onsU act, Repair. Renosate Or Demolish a Krri,rd.huni,u c �
One- or Two-Funiily Lit%eNing 'UUS
This Section For Official Use Only
Building Permit Umbe,.r::,� Date Applied:
Sixnat ore: ---
Building cone niss ter/ Inspector ut Buildings Date
SECTION 1: SITE INFORMATION
LI Property, :�d ress 1.2 Assessors Map & Parcel Numbers
.2—A cut / f l:=y -
I.la Is this an accepted street? yes '� no_ Map Number ParCCI Nwnber
1.3 Zoning Information: 1.4 Property Dimensions:
7nnin^_ Disirilt Proposed Use Lot Area isq IU Frontage (li)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
! Required Provided Required Provided Required Pruv ided
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1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'' M al ❑ On site disposal osal system
Public ❑ Private❑ Check if yes❑ ❑
p l
SECTION 2: PROPERTY OWNERSHIP'
2.1 capper'of Record:
�L�tGc�.�7
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Cl Owner-Occupied ❑ 1 Repaiis(s) Alteration(s7 ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Spccity:
Brief Descrip t)n t,Prop �edWurk': —V- S� S
c.L S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is de(ci mined:
❑ Standard City/Town Application Fee
.2 Electrical $
. - ❑Total Project Cost (Item 6) x multiplier .x i
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3. Plumbing S 2. Other Fees: $ �\
4. Mechanical (HVAC) $ List'
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check :\mount: Cash Amnon(: --
b, Total Project Cost: $ /J�co. CX> 0 Paid in Full 0 Outstanding Balance Due:_--___
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
License Number Ispir:uion Dale
Nance of CSL- Holder
List CSL'1'ypc(scc below) _
4ddrcss T .e Descri iron
C Unrestncled(tip to 15,000 Cu. 1-1.1
R Restricted IXe'_ Fanul) DttellmC
Signature bt Ntasonn Only
RC Residential Roohne Co\cmlt
Telephone WS Residcnual Windom ,utd Sidme _
SF Residential Sohd Fuel liurunm \ t ticmce In.l.d l.nnni
D Itesidenual Denwhuun
5.2 Registered home Improvement Contractor(HIC)
M Lh
HIC Name or HIC stranl i mew Registration N'unther
Addnassp I
F.x oration Date
Signalme Telephone
SE"10N 1: WORKERS' COMPENSAT!ON' !NSURANCL AFlADAVtT(M.G.L. c. i52. § =5C(6))
Workers Compensation Insurance affidavit must be completed Lind submitted with this application. Failure to pray ide
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 it
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
(, ____ as Owner of the subject Property here be
authorize _-_ to act on my behalf, in all maticis
relative to work authorized by this building permit application.
Si-nature of Owner _Date -- ----_ -----
�_ SECTION 7b: OWNEW OR .AUTHORIZED AGENT DECLARATION
i
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.
Print Name
Signature of Owner or Auther ized Agent Date
(Signed under the pains and penalties Of PCr Ll )
NOTES:
1. 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 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 and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.RG and 110.R5, respectively.
When substaatial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including garage, finished base ment/auics, decks or porch)
Gross living area [Sq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of halt/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open -- _---
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
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