1 LAFAYETTE PLACE - BUILDING INSPECTION � ' -. ,.�- ��o��d'
^ Thc ( uuunun�c�alth u� �\lass:irhuscila �
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i 13n�r� �it 13iul�iug Krgulatiuns ;�nJ St�nd;ir��
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l3uilding Prrmit Applic:niun To ('unstruct. Rrpuir. Rrnu�:itr Or I)rmuli.h a Kr� ��„ll„�r��.�� � '
U�ir- r�r Ttru-l'ru��ih' /hrrl/iiz,� / :i q�,S
'I�his Srcti��n For Olficial l;sr Onlv -----',
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I S(:C"1'ION I: til"1'F. INFOKJL�'PION
�.1 Pruperl�� .�ddrrss: � --- — .--_.____.-. .-- ,
i Yy�� 1._ .\ssessors .�I�p & Narccl .Vumbcrs
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L la I.� Ihis an urce led �IrCe[7 Yes_ nu__ �.�lap�\„r,i.... P:ircrl ,\uuthir-._____ .
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1.6 W'u[e�Supply: IM.QL e. �10. §S1) i.�7 Flooc 'l.bne lnforma.ina:�-----�--- - � .
I I.k Se��age Ditip>os�l 5}�strm: �
Lonc: Owside Flnud Z���r�c•�
�Publii ❑ Prn�ate❑ "--- ` \funici �I ❑ On .itc dis w<al s .�cm ❑ ��
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� SECTION 2: PROPER'i Y Oii'NLF:SIIIP� i
1.i Owner�of Record: � ------"----
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I �\'.w:�• �!'rinll (% �J�/ `"� , �ddrecy ti�r�crvice: �
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SECT(ON3: DEtiCRIPTIONOFPirOPOSeD L'f�Htiz rhecic �lt ha: 3raf.; �
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Nti�t�lun�.�� tiun ❑ t <�s[ � 6u:Iduig ❑ 1 (7•.�n�r `vr�op�ed�, I Rtpsu Is�� ❑ � li r.u:niiu) ❑ AJuih��n O�
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G�anc'i r�❑ ❑ Accetisury k i,1e. C L:u•n6er irf IJnit��,_ i (�t �cr u °� ._i��<--- i
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� .__ i I �hur md M,�trrials� Officiaf l 1 ,ify _�
1. liwiJing --_ �$ L 6wlding Permit F�e $��,n���:�;� h,��� ��� i` ����•i.i����� •J: !
'. F.lectrical . $ ❑ St�ndard Ci[y/Tuwn :\pplirann:-; :'rr
-- ❑Tutal Project Cu�i' (Item 61 s multiplicr__ r
�. PlumbinE �5 � _ '
_. O�her I'ees: 'S �
1. ,tiierhaniral 1i-11':1C1 S Lisl: :
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�u> fCui�rol � i ��nt:ll :\II Fee�: S_��__ __-_-__.____ , �
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i c, {'utal Prujcr[ CosL 's JU L __ _ ._ � �
. / /� O Paid in Full ❑ Ou:at:m�in�� l3;il:inre Uue:.-----
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SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor tCSIJ
N.uue III CSI.- Milder
\ddrrss
SI L'Illllllle
hekphone —_—
5.2 Retered Ito Is
Ii IC Company Name
Impruvement Contractor (IIIC)
HIC
Llccnse Numher
Lnl CSI- 1,\ pe ('cc heluw I
1`.\plralnal Date
I)o+.'nnnlrn
l tn'•solted till to IMAM I.L
R Reslrlcted l&2 Fannl\ Dwell
Al Al*1 Dnly
RC Re>Idcnual Rllotine( l)+crint
A'S Re'ldenllal \\'mJul..mJ SIdI
SF Re'IJcullal Solid Fuel 1$111111
Il u.•.�.I�•m i.l Delnuh uu❑
�/ 7.T�. �f
Telephone
Igll i,lnc In+l.il Lilum
Regbtralllnl Number
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SECTION
6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C'16))—
murance affidavit trust be completed and submitted with this application. F ilure to proIde
Workers Compensation I
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached' Yes .......... 0
No _...... _. 13
TO
COM ED WHEN
SECTION 7a: OWNER AUTHORIZ 0 PPI B FOR BUILDING PERMIT
OWNER'S AULN t APn � w,,L...-- --
as Owner of the subject property hereby
to act on my behalf, in all matters
authuril-r
etative to w•.>I k authorized by this building permit application.
Date ----
Si nature ut Owner
cFCT10N 7h: OWNER( OR AUTHORIZED AGENT DECLARATION
statement/s♦
SPP l7
as Owner or .Authorized Agent hereby declurc
ion on the foregoing application are true and accurate, to the best of my knowledge and
Signature tit Owner or :\uthorized .Agent
(,Signed under Ih a pains and penalties of I
d
Date
I. An Owner who obtains a building permit to do his/her own work. ur an owner who hires an unre��istered clllura.nlr
(not registered in the Hume improvement Contractor (HIC) Program). will 1101 have access to the arbill alion
program or guaranty fund under M.G.L. e. 11"_'A. Other important into, mation on the HIC Program and
Construction Supervisor Licensing (CSL) can be hound in 730 CMR Regulations 110.R6 and 1 10 R5. respectl+cly
When +ubstannal work is
Total floors area ISq. FI.)
I Gross living area (Sq. Fr.)
Number of fireplaces
I Number of h.rthroonts —
fpe Ill heating sys(cm __
Type of cooling ss?tem_
provide the information below:
(Including garage, finished baeement/atncs, decks or pnrchl
liabitable room count -----
Number of heciroums-----
Number of h.11l/b,uhs--
Number of decks/ p, aches
--
1. -Toed Project Square Footage" may be substituted t,lr ' Gaal Project Cost