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8 LOCUST ST - BUILDING INSPECTION (3) -� - 114 - 12- s �1 The Commonwealth of Massachusetts OF L q,>ti, Board of Building Regulations and Standards CITY M Massachusetts State Building Code, 780 CMR SA Revised Mar Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Annh r i _, cs Building Official(Print Name) : tgnat SECTION 1:SITE INFO . TION V r- 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1a Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3_Zoning Information: 1.4 Property Dimensions: N - 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: Public M- Private❑ Zone: _ Outside Flood Zone? Municipal LY 6n site disposal system ❑ Check if yes❑ 4 ',SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: R :J "- 'A y !go I,e,,., Of 970 Name rint) City,State,ZIP Loytea) �3 j7� 6G0 7 1rG.kcQe- IcriAl 2nwrC4.M No.and Street Telephone Email Address -'SECTION 3i DESCRD'TION 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 I Other ❑ Specify: Brief Description of Proposed Work : de WtAJOU15 L. 1n VU-6 914rSrsz ck�;,!e . .X j SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs:Item Labor and Materials _ Official Use Only;. 1.Building $ 2 Z Uc-V 1. Building Permit Fee: $,, Indicate how fee is determined:> 2.Electrical $ ❑Standard City/Town Application Fee �. ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Otbei Fees: $ 4.Mechanical (HVAC) $ / List. >. 5.Mechanical (Fire Suppression) $ Total All Fees $ Check No. Check Amount: `' Cash Amount: 6.Total Project Cost: $ Z 26'Ud ❑Paid in Full ❑Outstanding Balance Due: (� SECTION S:,.CONSTRUCTION SERVICES' 5.1 Construction Supervisor License(CSL) cs oS7� L/,32 S2 4 XaC dw*4 License Number Expiration Date Name of/CSL Holder ^^ List CSL Type(see below) No.and Street ;Type Descnption s. Q U Unrestricted(Buildings u to 35,000 cu.ft.) _.., "CCwfu-S ©I 4 0 R Restricted 1&2 Family Dwelling City/Iown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 9 70 77 (s 77,E k IV+Cq 7�-' e, IU [ Insulation Telephone Email address D Demolition 5.2 Registered Home Improve ent Contractor(HIC) ) e i� A/ut)1 btaa1 ///�3 i /Sr HIC Registration Number puation Date 11 C Company Name HIC Registrant Name (r�ntrra _e KV4-e_97��C'err.^(e 4 n Vf-4 No.and Street Email address �w$wN Mn - otgo4 � 7�1V73P- Ci /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 f the building permit. Signed Affidavit Attached? Yes .......... No........... ❑ SECTION 7a:OWNER'AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PTARMM y I,as Owner of the subject property,hereby authorize 'P t MAC ' `AC l) 0 a 0 to act on my behalf,in all matters relative to work authorized by this building permit application. 12a�4 bawd,4 �. -7 '-� i Print Ow er's Name(Elec onic Signatur Me SECTION 7b OWNER'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 application is true and accurate to the best of my knowledge and understanding. e d6tvZ,14 �A2c Print Owner's or uthorized Agent's Name(Electronic Signature) Date„ NOTES �..r ". .,tee � � z 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 mnD .mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/des 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 Cost"