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10 1-2 HERBERT ST - BUILDING INSPECTION :o � , � z � The Commonwcalth of M•rssachusrtts y ;� Doard uFBuilding Rrgul•rtiuns�nd StanJar�s CITY q� �� m OF SALF.M �7 Massachusras State BuilJing Cixic, 780 CMR, 7 edition � Rrvisrd Jurruury �� 13uilJing Pertnit Applicatiun To Construct, Repair, Renovrte Or Demolish a /. :rNAY Onr-or T�vo-Fumilv Dwr!ling This Section For ORcial Use Onl BuilJing Prrtnit Nu ber: Date Applied: ' �J � l�J� �J''� Signawrc: '/� �/ 77' � Y/ � BuildingCummissianedln torot8uildinya - Date � SECTION 1:SITE INFORMATION I.I Properry Addres�: 1.2 A�u��on Map Q� Parcel Numben /D%2 t���Fier7` ,tf" I.I a Is Ihis an accepted strcel?yes no Map Number Porcel Numher . IJ ZonlnQ Informatlon: IA Property Dlmenelona: Zoning District PropoxJ Use Lo�A'ea(sq Il) Fromage(Il) 1.5 Bu1ldingSetbacW(R) � Fron�Yard SiJe Yarda Rear Yard Requircd Provided Requircd Provided Required Provided 1.6 Water Supply:(M.G.L c.a0,§Sa) 1.7 Flood Zooe tnform�tlon: 1.8 Sew��e DLspoa�l Sy�tem: Zone: Oubide Flood ZoneT Public❑ Private O Check if a0 Municipel O On site disposal sys�em ❑ SECTION2: PROPERTYOWNERSHIP� 2.1 Owner�of Record: Nnme�Print) Addmst for Service: � Signmure Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK�(c6cek rll th�t apply) New Construction O Exisling Building❑ Owner-Occupied Repairs(s) Alleration(s) O Addition O � ��o Demolition O Accessory Bldg.❑ Number of Units_� Other O Speeify: � Brief De3cription of Proposed Work': � n ' o o�- �9O/oc MI�'�j Or�Sfi.�[_ Y'nt.il:� lairr6:.r��f��oin SECTION 4: ESTIMATED CONSTRUGTION COSTS tcem Estimated Cos�s: pmclal Ufe Only Labor and Materials I. Duilding S 1. Ouildi�g Pertnit Fee: f Indicate how fee is Jetermined: �. Electrical S ❑Slandard CitylTown Application Fee O Total Project Cost�(Item 6)� multiplier z 3. Plumbing 5 2. O�her Fees: S �. Mechanical (HVAC) S List: 5. Mrchanical (Firc S Su «ssion Tolal All fees: S Chrck No. Check Amoun�: Cash Amount: 6. Tofal ProJect Coft: S � D O p p��d in Full ❑Outstanding Balance Due: o� 7rl� t� h � � 1 SECTION S: CONSTRUCTION SERVICES 5.1 Licensed Com�ructlon Supervbor(CSL) p����— �� O � License Number :�pira�ion Uam N:une ul'CS I IulJer I.isl CSL�fype 1�below) (� � ..u,��i�n S /7a�61�/�IAD/6 � �.� ion :WJ s U Unres�ricteJ u Iu75.000Cu.F�. R Nestriated IB2 Fomil Uwellin _ tiign��u M M• (hd S' RC Rrsidentiul Roulin Coverin I'cl¢pMme WS ResiJemial WinJowandSidin SF Ra�iJenlial Sulid Fuel Bumin A lianae Install�iiu� D ResiJrn�ial Demoli�ian 3.2 R �teredHomel �provemeotContnctor(HIC) /�969/ sr f I IC mpan am ur f IIC egiatmm N:une � Registrn�ion Number � -�.,/� �' Cm.� .+a-far G � � G��P•� �,?•/8• /2 AJ.I�es / L/6��Q/! .rl� �la��EG�a:�ifRoRfC� SO��1$'•�S ��piration Datr tifgnumrc Tclephune SE ION ORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. f 25C(6)) I Worken Compensation Insurance afTidavit must be completed and submitted wi�h this application. Failurc to provide this affidavil will rcsult in the denial of the Issuence of the building permit. Signed ARdavit A[tached7 Yes .......... O No...........O � SECT[ON 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN II OWNER'S AGEIVT O CONTRACTOR APPLIES FOR BUILDING PERMIT � (��/�� ���' , as Owner of the subjecl property hercby aWhorize � � to act on my behalf, in all metters rclelive to o authori� y this uilding pertnit application. - O�- �� �D Si �ure of Owner Dnte SECTIOIY 7b: OWNER�OR AUTHORIZED AGENT DECLARATION � • ,as Owner or Authorized Agent hereby declare that�he statements and infortnation on Ihe foregoing app�ication are true and accurate,to lhe best of my knowledge and behalf. ` ' Prinl Name Siynuture o((hvner or Authorittd Agent Dale Si ed under�he aine and nolties of 'u IYOTES: 1. An Owner who obtains n building permit to do his/F�er own work,or an owner who hira an unrcgistered contractor (nol rcgistercd in�he Home Improvement Conuactor(HIC)Program),will�have access to the arbitrrtion . program or guaranty (und under M.G.L.c. 142A.Other important infortnation on the HIC Program and Conslruction Supervisor Licensing(CSL)can be found in 7R0 CMR Regu�ations I IO.R6 and I IO.RS.«spectively. ?. When substantial work is planned.Provide�he inf'ortnation below: Total Iloors area(Sq. Ft.) (including guage, finished bacemenUatlics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fircplaces Number of bedrooms Number of bathrooms Number oYhalf/baths Type uYhea�ing sys�em Number of decks/porches Type of awling system Enclosnd � Open� ). "Tu�nl Projacl Syuare Fiw�age"may be substiw�eJ for"Total Projrct CosP' ��_ � A � CITY OF S.�I.E.ti(, I�L�SS.�CHL:SETTS 8t:aD6VG Dl1ART1�iT • I'0 W.��+avcTon Snast. l"Ftooa T1�L (97�7iS9S9s F.�x(97� 7�496N K1�mEJ�-EY DR13C011 7110NAtST.Plu�li J�tAYO� DiRu-roa o�R euc rw►iarr/K anac coaons�taves WurYers' Compensstlo� In�urane���ffld��iC Ou1ld�ra/Contrutoe�lEleetrlelsaalPlrmAut a��nucant Infnrm�t�aw Pfe�t� MM LedSM vama�u..��.+.o.�,.�n�wi�.r.,�r►: ��°a�e _ ,�r��J — .1JtIRl�. I ('1/n��l��l7 )T //OP��rh�� /%/J �`����'� - c��y�sd�az�� /�1a�6 ,� � /'7A olyS�S rtwn.�►: SP114' • 72 s • �66 s .�..re....��.�..t c�a u.,��..�.a�.n ryw.ivwl«�(•wW►�+k I.O 1 am�.:+nyb�wiv ,�. Q i���nrnl cwts�or aa�1 6. ❑Ns cwaucua� .mylerew(IWI aoYe�partasrl.• h�v�hiier J�ai►saesaceA i. 1 am�aoM pa/ri��s ar p�nnan Iia�t1 aa drasaelr��hs�L= 7. 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