55 HIGHLAND ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'h edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair,Renovate Or Demolish a 413-596-2800
One-or Tiro-Fancily Dwelling Ext 118
This Sectio or O t 1 Use Only
Building Permit Numb a Ap lied:
Signature: �1+r�o /o a 7
Building Commissioner/Ingpector of Buildin s Date
SECTION l: E INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
SS H qh SJ— 5r (-w m5S
L l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensionsr
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
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 O On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' or of Record:
✓ or 0 L ---3"" nr SS N/ �t(il�vro Sr
IcLner'
Nage( mt) Address for Service:
Gf/12 Ile 9 7 '�- 7 y< 6 y3 47
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
EDescription
n❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
of Proposed Work':
2L A Wrm0 5 c h t(� s110
tA1 5' L IV4Ti.__ 2R,�C - e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $ "I--.
4. Mechanical (HVAC) $ List:
��i�
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
,Z[6. Total Project Cost: $ /$Qv 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) e
License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
Type Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number _
Address
Expiration Dale
Signamre Telephone
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
1 All lG ari ldar 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. -
�(/,.(G yu ,G ` 07 0?6-0 k
Si nature of Owner Date
SECTION 76: OWNERt OR AUTHORIZED AGENT DECLARATION
1 ,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 Authorized Agent Date
(Signed under the 2ains and penalties of edu
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and 110.R5,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"