195 JEFFERSON AVE - BUILDING INSPECTION W The;.-ommonwcalth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, T"edition 0000
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tiro-Famil Duelling �
This Sectio or 011iicial a Only
Building Permit Nu r: a App edj:
Signature: J° `7�OGi
Budding ommissioner/ specto of BuildiPA31Date
S CTIO INFORMATION
LI Property Address: 1.2 Assessors Map dt Parcel Numbers
. I.]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 n) Frontage(fl)
1.5 Building Setbacks(It)
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❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 yy+yyner'of Record: �o
�s�)"C " Jti c/, � -
Name(P int) Address for Service:
cf� Syr= 5�� 7
Sig azure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number o(Units_ Other ❑ Specify:
Brief Description of Proposed Work':
6 77
4
elf
f' s ir✓�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building f 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical IHVAC) S List:
5. Vechanical (Fire S Total All Fees: S
Suppression)
�'1 Check No. _Check Amount: Cash Amount:_
6, Total Project Cost: S SW 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 1)1 -
'' License Number Esptration ate
Ngr�of CSL-Hplder List CSL Type(.cc below)
T Description
Address
U Unrestricted(up to 33,000 Cu. FL)
Restricted 1&2 Famd Dwelling
Signature ! ? / M Slasonry Only
RC Residential Roofing Covering
Telephone w5 Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered dome ymprov eat Contractor(HIC) D 6 cCS 5 L�
�l l`�,/ /1 ooF n r/l
HIC Company Name or HIC Registrant Name gatration Number
Address
�ys- Expiration Date
Signature Telephone �/
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 153.1 25C(6))
Workers Compensation Insurance affidavit must he completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of d
Ite building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT
, OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/ —�Ze—,t/G 1,7 as Owner of the subject property hereby
authorize /L/ Yh, r r C e- to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1. Ar - ,as Owner or Authorized Agent hereby declare
that the statements and inf6rmation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
d
Signature of owner or Authorized Agent Date
70wner
r the ains and penalties of perjury)
NOTES:
er who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
istered in the Home Improvement Contractor(HIC)Program),will y2l have access to the arbitration
or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
ction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
bstantial work is planned,provide the information below:
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 halfibaths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may he substituted for 'Total Project Cost"