236 JEFFERSON AVE - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
W
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CMR $d Mar
Revised Nlur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
Chis Secttoa,For Official Use Only '
Building Permit Number: C7ate A d: , '
Building Official(Print Name) r lure
Daffi
SECTION I:SITE INFORNIATION
1.l Property Ad ess: � Ll Assessors Map& Parcel Numbers
Map TS
1.1a Is this an accepted street?yes_ no Nfap 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 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P P y
q 1 SECTION 2:;'PROPERTY OWNERSHIP"
mtc_L_/nX t't fRe�r !//�itl & )m�
A
\ Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': /riAcd ol1�l'rburlcl S`/r f� QIJZJ/
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Estimated Costs: 11
Item Offoial Use Only:.,
Labor and Materials
I. Building Permit Fee S Indicate how fee is determined:
1. Building 5- ❑ Standard. City/Town Application Fee
?. Electrical ❑ Cotal Project Cost(Item.6)x multiplier x
3. Plumbing S Other Pees:'S �
4. Mechanical {EIV:\C) S Li Lisf:
i. Mechanical (Fire $ Cowl:\Il Fees: S__
5n ression) _ -
Check No.. Check Amount: Cash Ainowit-.
G. "Total Project Cost: S 1>7-U6-61U 0 Paid in Full ❑ Outstandin, 11:11ance Duo:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
License Number G.epiratiou D;ttc
Name of CSL f lolder
List CSL Type(see below)
No. and StreetrYPe Description
U I Unrestricted Building s u to 75,000 cu. tt.
_ R Restricted 1&2 Family Dwelling
City/Town,State, ZIP ib( i\lasonr
RC Ruofing Covcrin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
fele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
f IIC Company Name or MC Registrnnt Name
No.and Street Email address
City/Town,State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. t52. § 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
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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 plic, is t fuc and accurate to the best of my knowledge and understanding.
r
tit Owner'.;or A thuriied:lgent's Nmne(Electronic Signature) - Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(H[C) Program),will not have access to the arbitration
program or guaranty find under M.G.L. c. 142,\. Other important information on the HIC Program can be found at
%ww.ncus.,ovioca Information on the Construction Supervisor License can be found at uww.ntass.� o�clo
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.). _ —(including garage, finished basement/attics, decks or porch)
Bross living area(sq. it _ _ Ilabitable room Count
NuntberoFfireplaccs._ - — Number of bedrooms ---- ------_--
Number of badirooms Number of h;dbbaths ---- _
[fvpu of hoating sy,tcn - __-_-.--- _---_-- Nuutber of decks/porches
1)peofcoolingsy;tent_._--- __---- Enclosed— ,_-- --,Open --
i I tl PI ojcct Co,t"
i "foal I'rojert.lquaro Pu�,t;t,r utav Lc snb;nnit�� t;�r� 1�,� .