33 INTERVALE RD - BUILDING INSPECTION The Commonwealth of=OrDemolish
wn of
Board of Building Regulatids 70
Massachusetts State Budding Coda edition Building Dept
` giga
Budding Permit Application To Construct. loomww
te Or Demolish a
One-or Tiro-Fanult•
This Section For Official Use Only
Building Permit Number Date Applied:
Signature:
Building Commissioner/Inspector of BiWdings Dole
SECTION 1:SITE INFORMATION
1.1 Property Address- 1.2 Assessors Map& Parcel Numbers
,; 2 7 t - m�
I.1 a Is this an accepted street'?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
zoning District Proposed Use La Area(sq ly Frontage Itt) -
I.S Building Setbacks(ft)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c. 40.154) 1.7 Flood Zone Information: 1.111 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private 1 Check i! es0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'o!Record 1!2t
Name(Print) Address for Service:
0- Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O 1 Repairs(s) O 1 Alteration(s) O Addition O
Demolition O Accessory Bldg. O Number of Units_ I Other O Specify!
Brief Description of Proposed Work':
9
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllclal Use Only
Item Labor and Materials
I. Building f I. Building Permit Fee: f Indicate how fee is determined:
a Standard City/Town Application Fee
2 Elecincal f p Total Project Cost'(Item 6)x multiplier x
J Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) f List:
S Mechanical (Fire f Total All Fees: f
Su resston
_ Check No. _Check Amount: Cash Amount:
is Total Project Cost: f �lj�j, 0 Paid m Full ❑Outstanding Balance Due
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Constructlo Supeni or(CiF;
'' \//,1 Numher Esptntion Dore
/`mil�� / �[
Name of CSL H Idcr / CS T� Yptlx'e lrcluw)
Descrn non
Unresntcted u to)5,000 Cu. Ft.Restricted IA2 Famd DwelhnSignature c? Mationry,Only
o J RC Restdennal Roofin Covenn
Telephone svS Rest den
nal Window and Siding
SF I Residential Solid Fuel Burrionst Appliance Installation ,
D 1 Residential Demolition
5.1 Registered Ho e 1 prove eat Contractor(HIC) loG�s`L/
YJA
ocF—r
HIC Company Name or HIC Registrant Name 'Registration Num
bfii
g/fl-
Adthess _ pmtio ate
Signature Telephone �f
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISt 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? Yea.......... O No...........O
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 /V/ r`r li r r� to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER'RR AUTHORIZED AGENT DECLARATION
1, / ��- , as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoa g application are true and accurate,to the best of my knowledge and
behalf.
S �
Rine Name _
o O
Signature of OwOkr or Authorized Agent Date
Si ned under the pains and penalties or 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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I I0.11S, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/anics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
.Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of healing system Number of decks/ porches
Ts pe of cooling ayuent Enclosed Open
1 Total Project Square Footage"may he substituted for Total Project Cost"