11 LOCUST ST - BUILDING INSPECTION i
I`
1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards POR
�`.�� Massachusetts State Building Code, 780 CMR, 7"'edition MUNWIP:ALI"I y
< USE
Building Permit Application To Construct. Repair, Renovate Or Demolish a Rrrisrd Ju,n„n,
One- or Tiro-Fainily Duelling 1. _'Uu$
This Section For Official Use Only
h Building Permit N mber: Date Applied:
`N Signature:
Bw ding Commissioner/ Inspector of Buildings Date ((
SECTION 1: SITE INFORMATION
1.1 PropLerty Address: 1.2 :assessors Map & Parcel Numbers
1 l oc U5T T
I.la Is this an accepted street'? yes no Map Number Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage tli)
1.5 Building Setbacks(ft)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
E1.6Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
ic❑ Private❑ Zone: Outside Flood Zone:'Check if yes❑ On site disposal systemSECTION 2: PROPERTY OWNERSHIP'
. Owner'of Repcord:
AL 7r lA0 II LnCU-St' Sz-
Name (Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied Repairs(s). ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specity:
Brief Description of Proposed Work': R, T f 7A( .v 4z yn IF j 2 b,F f-�,� S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project 3. Plumbing Cost (Item 6) x multiplier ,x
$
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su ression) $ Total All Fees: $
b. Total Project Cost: $ i G� COt7 Check No. Check Amount: Cash :\mount
tJ ❑ Paid in Full ❑ Outstanding Balance Due:
-SEE G7IIC rl-41 �1 F'_ rCo_wt. lit/LvS Z i- 121 M '% Ztt1m aV(s�
r
SECTION 5: CONSTRUCTION SERVICES
r:::
icensed Construction Supervisor (CSL) �� p
License Number G-\piston Date
o ��bbt,vs
of CSL- Holder A w List CSL'fype (see below)
� 9 NI/1 C'1'-�-o/-t 6 SD D V M 6 Type Description
s Q u Unrestricted(u to 3SA00 Cu. Ft.)
n--e R Restricted Ide'_ Famil ;D�eelline
Signature WDR,�'stuunnal
nl
C�-)Q �--� ( Q3'-� Residential Rooting CuPcrine
"telephone - -1. - - l \Vinduw :md Sidin
l Sohd Fuel [awnIo2 .A tli:uxxe In6tallauuu
l Demolition
5,2 Registered Home Improvement Contractor(HIC) / b 0 s ( t
C�"''T Registration Number
HIC Co
,7any Name or HIC Registrant Name e _ z3—/D
1 �! _,
Address Cy,-���'�( �'�3t-\ Expiration Date
Signature !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 ...... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
f, to act on my behalf, in all matters
authorize
relative to work authorized by this building permit application.
Date
Si nature of Owner
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
`F,, ( )(2s,
Print Name
G
Date
Signature of Owner o orized Agen
(Si ned under the 2ains and penalties of er'u ) -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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively.
Whensubstantial work is planned, provide the information below:
(including garage, finished basemendattics, decks or porch)
Total doors area(Sq.Ft.)
Habitable room count
Gross living area(Sq. Ft.) Number of bedrooms
Number of fireplaces
Number of half/baths
Number of bathrooms
Number of decks/ porches
Type of heating system
Enclosed Open
Type of cooling system
3. "Total Project Square Footage" may be substituted for"Total Project Cali' _.