469 HIGHLAND AVE - BUILDING INSPECTION C rr /c�Y 3 � 5 D o
y
The Commonwealth of Massachusetts Town of
Board Building Regulations and Standards
Massachusetts
State Building Code, 780 CMR, Ts edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tiro-Family Dwelling
This Section For Official Use Only
Building Permit N //her: Date A lied:
Signature: 411 0
Building Commissio /Inspector of Bu s Date
SECTION WSITE INFORMATION
1.1 Property AdQI�s •}��,// 5 4�GaGt' 1.2 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 fl) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard ide Yards Rear Yard
Required Provide Required Provided Re Provided
1.6 Water Supply:(M.O.L c.40,§M) 1.7 Flood Zone Information: 1.8 Sewage Dis em:
Zone: _ Ou ood Zone? Municipal❑ On site disposal system ❑
Public❑ Pri heck if yes❑
SECTION 2: PROPERTY OWNERSHIP' )),,
2.1 Owner o XI'li v U/ for 9
NamPnt) Address
Service:
Cl�� a 3-)
• /\/ Q. '
Signature
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing ilding❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': -e n r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllclal Use Only
Item Labor and Materials
1. Building S I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing b 2. Other Fees: b
4. Mechanical (HVAC) S List:
5. Mechanical (Fire
$ Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ /0/ 0 1-) 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Ngme of CSL- Helder
List CSL Type(sec below)
Address T es[n non
U Unrestricted to 35,000 Cu. Ft.)
Signature
R Restricte &2 Family Dwelling
M Mas Onl
RC idential Roofin Coverin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Bumin Appliance Installation
Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration N mber
Address /
Et ira[ion Date
Signature —t Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be eted and submitted with this application. Failure to provide
this affidavit will result in the denial of the ance 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. !,
Signature of Owner Date
/� SECTION 7b: OWN
EER
/t OR AUTHORIZED AGENT DECLARATION
X4 AVE L L M E /V A 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.
PAVCL M ENN f
Print Name s
02 - Z.S- 2009
Signature of Owner or Authorized Agent Date
Si ned under the pains and penalties of perjury)
NOTES:
I. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I I O.RS, respectively.
2. When substantial work is planned, provide the information below:
Total Floors 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"may be substituted for"Total Project Cost"