12 LARKIN LANE - BPA-14-1721 CGS
L 1
( The Commonwealth of Massachusetts
Board of Building Regulations and Standards CR N L SJMIS
assachusetts State Building Code, 780 CMR IHSPE
M Revised,t1ur 2011
p, 43
Building Permit Application To Construct, Repair, Renovate Or Demoli y O
One-or Two-Family Dwelling 10�4
This Section For Official Vse Only
Building Permit Number: Date applied:
PAY f
Building 011ieiul(Print Name). Signature Date
SECTION I:SITE INFORMATION
1.1 Property dress:L���t.� ` 1.2 Assessors Map& Parcel Numbers
I.la Is this Jan accepted street?yes V1— no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
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 [3 On site disposal system ❑
Public❑ Private El Zone:
if es❑
SECTION2. PROPERTY OWNERSHIP
2.1 Ownerl of Rccof110. f 9 �' , DS pq '� M /� /►
�hme(Print) CCaa City,Slate,ZIP
a La i 6 7 - SG
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Cl Existing Building❑ Owner-Occupied ❑ Repans(s) Alterations) ❑ 1 Addition ❑
Demolition Cl Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work%
-y Kl L. Ir0. C2 Yr. B r1
C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Casts: Official Use Only
Item Labor and and,
I. Building S 1. Building Permit Fee:3 Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost}(Item 6)x multiplier x
3. Plumbing S P 91her Fees: .S
-1. `Icclimical (fIVAC) S List:
i. Mechanical (Fire S Total All Fees: S
Suppression)
Check Na. Check Amount: Cash Amount:
G. Total Project Cost: S -7 ❑ Paid in Full ❑Outstanding Balance Due:
CfL�Nt 0 (.J 11�O p W
II
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructioh'Supervisor Li f cerise(CSL) 4 ?�a
' •
•p�� `-a, C h S,• License Number Expiration Date
Name CSL`(folder *;n
' List CSL'rype(see below)
P, o ax 9�
No. ;md Street Type _ Description
U Unrestricted Duildin s in)to 35,000 cu. 11.)
of R Restricted 1&2 Family Dwelling
Cilyllbwn,State,ZIP O I QS� M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Ib O� 1I Insulation
'rcle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) � f 3�J 1� /q
/
( f-C, ` �( W -, e,J Des R C,h.- C r� t� HIC Registration Number Expiration Date
HIC t;.6illpaD c o;S[ iltegistmnl Name C
No.bv) clef, u � l' ' / \ /�1b — �(/ Email address
r�yl `I',v` l, '
Ci /Town State',ZIP �J� 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No........... O
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize ' ' OA' C t°`j
t9 act on my behalf,in all matters relative to work authorized by this building per t application.
sE C � t>V\trC, Iv
Print Owner's Name(Electronic Signature) Dale
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 n tis appl on i rue and accurate to the best of my knowledge and understanding.
6
Print Owner's or Authorize)Agent's Name(Elecuonic Siguauve) Date
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(IIIC) Program),will noj have access to the arbitration
program or guaranty fund under 1I.G.L.c. 1 d2A. Other important information on the HIC Program can be found at
�eww.mass. •ov:'oca hiformation on the Construction Supervisor License can be found at otvw.nmss.wv!JL .
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) ' ,(including garage, finished basemenNattics,decks or porch)
Gross living area(sq. 0.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type ofcooling system Enclose) Open_
3. "Total Project Square Footage" may be substituted for""rood Project Cost"