8 INTERVALE RD - BPA-2008-2046 (- 2�y �
file ('oihnnatasralth of IMas.arhusells
y linard of Bwlding Rcgulafiuns and Slandaids I t dt
%lassdChusMS State Building Code. 78U ('MR, 7"' edition 'M S'I( H, \1 I I
.....� I .tit.
Building Permit Application To ('011SIrur1. Repair. Renovate Or Delluli
! 0/1e- r,r Tiro-Family Dtrrllur.¢ n,y
I
This Section For Official Use Onl_Y �I
Building Permit Nunt —
. Dale Applied: roe 1'Z� C O h�
Srvnature: _ — _ _G• l2. 06�— ----------
Budding -'oned Inspeclur of Buildings
SECTION 1: SI'1'F. INFUKALY TION
1.1 P7 rh' Address: 1.2 Assessors flap .@ Parcel uutnher; ----- — --
re
I_I:I Is this :III aCCC pled .:I1YCt.• I __ Ili I Slap Nluio ei— -- r•aree \tinlhCl.--_�_—.
1.3"Zoning information: 1.4 Property Dimensions:
— — -- ..
P {l) Illi Pr11pUXd l]t l 11 '\ .i 'Sy r.. --...—_ Fl Ulliu Li Ilf)
1.5 Building Setbacks (ft) J
Front Yard Side Yard, Rear 1':ud
ReyuireJ Provided Kc• uucd
—._—�__._�_ Provided Rryuircd PnniJrJ
LS R'ufer Supply: (M.G.L r. 10. §51) 1.7 F;uod Zone Information: l.8 Sewage Disposal System:
Public ❑ Private ❑ Zone: ._ Outside Flood Zone? I
Check ii yes❑ �btumcipal ❑ On site Jislwsal tiysle ut ❑
_ SECTION 2: PROPERTY OWNERSHIP1
2�nertof Record• —i
LLL�r< h�KS k,'
N'.uoa iPrint)
Address for Sgrviee
I --- -2 7 74f- 4( z y'�
Signature Telephone ---
I
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) i
New Construction ❑ Existing Building ❑ 1 O,.cner-Oecupied ❑ Repnicsls) �@7 Alterntionl s) ❑ :\Jddl,m ❑ 7
Deniolidori ❑ Accessory Bldg. ❑ Number of Units Cther ❑ Specify: j
H ief Description of Proposed Workr: t-�—u
�tI vc/2 �JVS! wp•-a o /2r t>11ci, — 6«l_'.Ck. :A"�-. Si �`/_.--
SECTION J: EST►b1ATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only(Labor and Matenals) y
I. Building g I. Building Permit Fee: S. Indicate hou fea is delernuncd j
2. Electrical g ❑ Standard City/Town Application Fee
❑ Tidal Project Cost' (hem G) x multiplier .x _
3. Plumbing S ?. Other Fees: .S �J
4. .tilechanical IHV:\CI 'S List:
5. Nlechunical (Fire
AI ) ression) � Total :\II Fees: 5 ---------
Check No. Check Amount: _('a.h :\ntouni
-
o Total Prnject Cost S ZZ.Cj�f ❑ Paid In Full -- --
❑ Outslanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) �y 437j4 _—
Lucnse Number I:v{n slum Uala
Nance al CpSI.- Ili Weir / Q`%�H / d 1,1, CSL Cep¢ I•¢e helu�r 1 L�
f zVa 9df'le, (G 1!Ji rlt P I-V, e Dcsiri tUan
t =� F
l -tlU
WJIeN R 1 _' F.umh Dtt]i,�i!;w e \t nly7 0 RC RnuUncl'utrnn`\1'S \\induo .inJ >I elrphonr1F S:JiJ Furl low nineD Urululm"11
5.2 Regis(7ered Ilome Itnproeernenl Contractor IIIICI j3`�(°
V,% 4-U y e Regntrauun Number
Hll' Cotn)any Name or I C Ra� trD h�c -/ A•
Address _ 'j y'� 5 Fs piratiun Uuta
'!'elepltnne __
s gnu
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed :md submitted with (his applicauun. Failure to pnn Ide
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
as Owner of the subject property hereby
1. _-__------ to act on my behalf, in all mMIels
authorize
i
relative to woe k authorized b) this building permit application.
signature It Owner
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1 ��� L , as Owner or Authorized Agent hereby declare
(hat the statements and information on the foregoing application are true and accurate. to the best of my knowledge and
behalf.
i
u
Print Nat fZ Ug Date
Sign❑ cut Owner or:\uthunzed Agent
I Si neJ wtJer the puns and penalties Of era 0
I. An Owner who obtains a building permit to do his/her own work. or an owner who hires an unregistered omit-3 01
(nut registered in the Hume Improvement Contractor
actor(HIC) Program).6ram), will not have access to the athi(i alwn
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 C'MR Regula(ions I IO.R6 and 110 R5. respecinely_
When Nubstannal work is planned, pnnlJe the informationbelow:
aragr. finished basemen Uatucs, decks or porch)
Total flours area !Sq. Ft.) - Habitable nnlm count --- --
! (truss living area (Sq. Fr.) Number of hedrrnnns _._ --_-----_—_--
Number of tlreplaces Number of halt/h,ohs --
1 Nllltiberot h.uhruums Number lit decks/ pt�rches .__ ---- ---
LpF�pe
oef
e nt heating Nystem _ - 6nclnsed _ v Upon
ruining NcstemTo(al Project Syuare Footage" maybe ellbNhtuied fur ' rotal Pnrjecl C o,