4D HART WAY - BUILDING INSPECTION The (lann onwealth o[ Massachusetu
t Board of Btululing Regulations and S(aidaids ItCN
\II NIIIP \I II 1
Massachusetts State Building Code. 7SU (AIR. 7°i edition I SI \ems
Buildin 1g ermit Application To ConSlrurt. Repair. Reno%ate Or Demo,li>It a RrI
One- ur Tuts-l•iunih Dtrrl/inq n,\'
—=—i
This Section Fur Official Use Only _ !
7
BwlJine Permit Number: - Date .-Applied: /7 d
Build �C, nnu"loneli to •.lur,d Bmldmge Date
SECTION 1: SITE IN'FORNIAI.ION
1.1 Property . ddress: 1.2 Assessors .Map ON,, Parcel .Numbers ,
yam_-�� -----------
r
_a %la hcr P.,rel ,A'unlher
la
I. Is this an accepted surer'. � no_ P IN'uln .— ---
1 1.3 Zoning Information 1.4 Prouer(_,' 9;-ncnsit;ns:
"Lining Uatnc: Proposed Use — I Lot Area(sq it) Fi uutuge (li)
1.5 Building Setbacks(ft)
rFront Yard Side Yards Rear Ywd
! Required Provided Regm:cd _ PnwiJed Required PnniJcJ
1.6 Water Supply: (:M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone _ Outside FIouJ Zone" Nlunici al ❑ On .ire Jis xsal ti +Iem ❑
Public ❑ Private❑ Check if yes❑ P
SECTION 2: PROPERTY OWNERSHIP'
2.1 ( wner'of Reco d:
_� Sl ,D A1ARr
.N,urr Print; Address rot Service:
I �iun.lure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
--r —
. New Cuc,truction ❑ I Existing Building Owner-Occupied RepalrsU) Aiteruiun(s) :\JJllii:n ❑
Demoliucn 0 Aceesnory Bldg. ❑ Number of Units_ Other ❑ Spealy:
��
--
I -
SECTION J: ESTIMATED CONSTRUCTION COSTS
stimated Costs:
Item C E
I-abor:md Materia Is)
Official Use Only
I Buildine `$ I. Building Permit Fee: 3 Indicate hook fee Is J��e/ttermined
❑ Standard City/Town Application Fee 44-7 /
?. Electrical Y ❑Total Project Cost' (Item 6) x multiplier s _
3. Plumbing 5 Li
Other Fees: $
J. Mechanical (HVAC) 5 List �} —
i
5. Mechanical (Fire ---_----
) Total :All Fees: 5
Su t cession)
Check No. Check Amount Cash :\nnnuu:
0 rotal Project Cost: 5 �6op I 0 Paid in Full 0 Ou N(anding B;Il;mce Due:
SECTION 5: CONSTRUCTION SF.RVIC•ES
_5.1 Licensed Co//nstruction Supervisor (C'SI.)
M.0 .�.-0 �� u..uS l_I.in.a .Nuinher I`.spir.wou Data
'same oI ( SI-- Ifolder ��
O V07N N[ � „� ^ I-io( CSL. l\pe i.ee helo%r 1
\J TF//LYKJ�t. /OCt_)raJ� l v e DCsi ri tUi�n
L t luestrlcled in t(u :S1)1)0('a. 1:1 ---,
-- — R Reslimed 1&2 F.umlk 0t%elline
Signal %I %LP101lr\ Onle
_4-71 i 9= C✓�i'OO HC Readenual Kuginc ('n`elm`_
rClephurie I HeadCuual .mJ S_.lu�_
SF HeaJCllll•Il Solid 141e1 limmne \ _ni_Iu'i.d Lni'm y
D Rea Jeun.11 Deinollo11
5.2 Reyistered Inure Improvement Contractor(IIIC) — --
111C N L /Y1 tG1C 4 �-��G
IIIC mnp;u � Naas ur FIIC Hi lranl um—� Reeutrpuun \'unihrr
oo� yo ��/ �'rAha�M MA oi9��7
Addre - ----
_ � F.xp�r:U ion.D:nc '
Signam e — 'relephuric
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. S 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. F duce to pnik Ide
this affidavit will result in the denial of the issuance of the building permit.
Signed Atfidavit Attached? Yes .......... ❑ No ........ ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S .AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. _ , as Owner of the subject property hereby
authorize to act on my behalf, in all matml:S
re!ative to wink authorized by !his building permit application. j -
i
Si nature of Owner ---_—_ — Date
�j SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, �jre 111,40,u[ , 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.
Aunams
n
Authorized Agent Date
ams and enalties of eru .) NOTES:o obtains a building permit to do his/her own work,or :mowner who hires ;in om eelsrcred Cntra,for
d in the Home Improvement Contractor IHIC) Program), will not have access to the ;ithitruion j
program or guaranty fund under M.G.L. c. 142A. Other Imporrmt in lot mat ion on the [I IC Program :md
Construction Supervisor I_icensi ng (CSL) can be found in 780 CMR Regulations 110.R6 :I nd 110,R5. IespeCnscly
When Substantial work is planned, provide the information below:
Total floors area !Sq. Ft.) (including garage, finished basemenUaturs, decks ur porch)
Gross living area ISq. Ft.) Habitable room iounl
Number of fireplaces Number of hedroom.,
I Number of hathioonls Number of ImIt/baths .---------_—_-- -..
l\pe of hennne System _-- Number of decks/ p,,t,hcs -- -- --
Fype of :oolow Sy Stem I[Ileltl]ed -- —--Upon _- .---- —_ --
i. 'Total Project Square Footage" may be Substituted flit "ford Project Cost. �