Loading...
20 LINDEN AVE - BUILDING INSPECTION (5) � K The Commonwealth of Massachusetts ( GEfYEt Board of Building Regulations and Standards.,tcl1MAL SE RV lC TY SAM Mar Massachusetts State Building Code,780 CMk Revised Mar 2017 , Building Permit Application To Construct,Repair,Renovatej%D aP One-or Two-Family Dwelling a This Section For.Official Use Only Building Permit Number. Date 4, lied: Building Official(Prier Name) . '.Signature::,:.. - SECTION I:SITE INFORMATION M 1 perjy Address: � 1.2 Assessors Map&Parcel Numbers 1 L l a Is this an accepted street?yes_v no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 15 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided �/& 3/ 30 ' 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public t/ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2p PROPERTY OWNERSHIP" 2.1 Owriert of Reco d: � �( —A u D rT7 /�4 �.(2©A/Al t9L �7—�17 Mg G l mil'70 Name(Print) City,State,ZIP ao �-(A) D,;�:4) AVES,k-en A4 973-�y-S�) � bra-a74 X. 0171-( No.and Street r ©(rj` Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work2: /aa/ 3 /l�� ZFS � e� Zs/� c 2 r2r3f31FP Z 'pHJC's SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials 1.Building $ v7 k�2 1. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical g ❑Standard Cfty/Town 9pplication Fee ❑Total Project CosCe(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire $ Suppression) Total All Fees:$ , Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ [3 Paid in Full ❑Outstanding Balance Due: 40 SECTION 5:'CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) [ /-7 'R'-)"-0, ' l9 �� (L License Number? Expiration Date Name of CSL Holder List CSL Type(see below) l-7 « D<; w AV 0(--, Type Description No.IStgeet . ._Y/ et O / (� Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Rooftg Covering WS Window and Siding SO& p 3� Cm�le I Solid Fuel Burning Appliances r `jj (a' � Insulation Telephone Email address D Demolition 5.2 Registered HTog,1/g Improvement Contractor(HIC) /D 29 GO 713 11-e r d7 D y '"�d ' HIC Registration Number Expiration Date WC—Co Na�mme or HIC Re strant TT�Jgt��� 'l✓ /�ly/7�z�4gJ Email address City/Town, 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 Issuance of the building permit. Signed Affidavit Attached? Yes ..........O No.........r;9!� 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 13 t9i e-4t, 'R 0 J c4c, f -- 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--OWNERr OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information con " ed in this application is true and accurate to t of my4wowledge and understanding. 2 at, �-ac9 JC(I Print Owner's or Authorized Agent's Name(Electronic Si ) 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at mn8 .mass. ov/oca Information on the Construction Supervisor License can be found atmo87—.m—ass.gov/dM 2. When substantial work is planned,provide the information below: Total floor 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 half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cosf' 7�4'Ity, 'c'4