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12 INDIAN HILL LN - BPA-16-358 Z© � The Commonwealth of MassachuseCiS Sl E ARA 0 0 a Board of Building Regulations and Standards FR 1GE SCITY OF L $ t Massachusetts State Building Code, 780 SALEM APR 15 A $ ftrisedMar2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a 1 One-or Two-Family Dwelling 9 This Section For Official Use Only � Building Permit Number: Date plied: (/ Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1 11 Property Address: 1.2 Assessors Map&Parcel Numbers '�Cy rNa(ay. JAM Leto - Ll a 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 ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yazd 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 GY Private❑ Zone: _ Outside Flood Zone? Municipal Er On site disposal system ❑ Check if yesll>/ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: (�Oxr'vr- Aheav ^ -Soil w. yxn 01970 Name(Print) City,State,ZIP I\ Lndlan Hill Lew, 176477-9/5-/ No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: rcNrolde K1lt4,A Brief Description of Proposed Work': a +✓c l xA- r Aw#-/^ Ilaww e_ (�� ' L sktl( New 4yanr7-c Ca rrlui n � [e Mrc +ilc Qatks��eah. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 0.00 I. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ` ❑Standard City/Town Application Fee ��0' ❑Total Project Cos[ (Item 6)x multiplier x 3. Plumbing $ 1000. 00 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 19 L/00•00 ❑Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) _ u� C,S-o873Sy v-.�8--17 1Rt'}Gr QGVCWfi k License Number Expiration Date Name of CSL Holider List CSL Type(see below) a1 Cglltr 54- SQr No.and Street Type Description o. ape t YK0. OI 9�S O Unrestricted(Buildings u to 35,000 cu.ft.) ��-r{ Restricted 1&2 FamilyDwelling City/Town,S te,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances %375--a96Q Puler $aeaidg I Insulatio Demolitin Telephone Email address D on 5.2 Registered Home Improvement Contractor(HIC) {cL f / 17994 S /G rr,biis�r icfmo eY� c f Lry HIC Registration Number Expiration Date HIC CompN y Name or HIC Registradt Name 21 rcdleVcl Sc.tIL 2 �(CYi3ggare��4 �camcoo� •N�f No.and Street Email address P,��roJ„ wtw at4(o 9�g,?�s-ayF9 Ci /Tow , State,ZIP 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,as Owner of the subject property,hereby authorize J '�L( GggA ,rG 6/1v b U hL/wJ A to act o b It IfaIf'i�rs relative to work authorized by this budding permit application. 1111211(, Print wner's Name lectronic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this a ication is true and accurate to the best of my knowledge and understanding. Print Owner' r Authorized Agent's Name(Electronic Signature) Date 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 can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work is planned,provide the information below: Total floor 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"