2 KIMBALL CT - BUILDING INSPECTION (2) k �7 3,S 7 0
'rhe Commonwealth of Massachusetts RE ,('E� &
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SALEM
Re Vej4ATV0/1
Building Permit Application To Construct, Repair, Renovate Or Deism[ A
\ One-or Two-Family Divelling
3 This Section For Official Use Only
Building Permit Number: Da Applied:
Building Otticial(Print Name). Signatpre Date
SECTION I:SITE INFORMATION
_ 1.1 Property Address: 1.2 Assessors Ninp& Parcel Numbers
? J.l /3N'LL
I.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 Arcsq 11) Frontage(Il)
a(
1.5 Building Setbacks(R)
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 yes13
SECTION2: PROPERTYOWNERSHIP�`
2.1 Owners of Record: /yJ
44(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 ❑ I Accessory Bldg.❑ I Number of Units_ I Other ❑ Specify:
Briet'Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building g �� ,�v I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical i ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 2`p Other Fees: .S
d. Mechanical (FIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: 1i 9 00 • oo ❑ Paid in Full ❑Outstanding Balance Due:
cra�L- Lo-I-A.qE:� ���� � ��G a .zq I
52 "0rnPCAINC solks0U'S-• eN mpgt —
f.r SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supeivisor,Liccuse(CSL)
<<a S.cF.off - �!/y �CtiJ License Number Expiration Date
Name of CTS�L�tfulder" F�.71 List CSL'rype(see below) l�
�G- s Type Description
No. ;ad/Street
U Unrestricted(Buildings tip to 35,000 cu. 11.)
Restricted 1&2 Family Dwelling
Cityfl'uwn•State,"LIP M Nfasonry
RC Roo fing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
-f(baS$S/ �L�!/�✓L2 .¢pL� 1 Insulation
'role hone Enmil address D Demolition
5.2 Registered Home Improvement
Contractor(HIC)
HIC Registration Number Expiration Date
HICC( onparty Name or HIC R. gi fit Nam
No. . ml Stree 4 ZOS Email address
El d G ��
it /Tos(n,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 Issuanc 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 -
t9 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
containe this a ication is true and accurate the best of my knowledge and understanding. .
Prit Owner's or Authorized Agent's Name(Flecuonic 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 rout have access to the arbitration
program or guaranty fund under NI.G.L.c. I42A. Other important information on the H[C Program can be found at
�sww.mass. •ov:'oea Information on the Construction Supervisor License can be found at% w.ntas..�ov/,Ias .
2. When substantial work is planned, provide the information below:
Total floor area(sq. R.) " (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Nunnber of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type ufcoolingsystem Enclosed Open_
1 "Total Project Square Footage"may be substituted I'or-rot l Project Cost"
i