6 LORING AVE - BUILDING INSPECTION 1
��� The Commonwealth of Massachusetts
"uil'di
CITY
dition ReOv sr ed January
Permit ytgplication To Construct,Repair,Renovate Or Demolish a 1, 2008
� � One-or Two-F,dmily Dwelling
This SecSi n'For Official Use Only
Building Permit N ber: `date A liodc"
9 gnature: ..� �� ! Q
Buildin omruissionei/InTecorofBuildmgs - Bate'? r
1„ �`. SECTION 1 SITE;INFORNIATION
1.1 Pro erty Address: �JA� 1.2 Assessors Map&Parcel Numbers
1.1a Is this an ccepted street?yes ✓no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
-SECTION 2. PROPERTYOWNERSIAIPJ
2.1 Owner'of Record:
Name(Print Address for, ��.Scrvicc:
Signature Telephone
SECTION 3:DESCRIPTION OF PROFOSED'WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
T ram' il� � i
ili G w 6
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ I. Buildmg;PermitFee: $ Indicate how fee is determined:
'❑Standard:CitylTownApplibationFee
2.Electrical $ a
❑Total Project Cost (Item 69-�z multiplier x
3.Plumbing $ 2 0ther Fees $ 7-
4.Mechanical (HVAC) $ Ltst '
5.Mechanical (Fire $ _
Suppression) "Total All Fee .
Check No. heck Amount Cash Amount:
6.Total Project Cost: $ a �� 0 Paid in Full ❑ on
Balance Due:
�.
SECTION 5 rCONST-RUCTION=SERVICES
5.1 Licensed Construction Supervisor(CSL)
M (U a lf L License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) I/
Address T?escri tion'
. ZZ � `�� U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Sig _ M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re istege H to I provement Contra for HIC)
� L�
HIC Copan Name or C Reg t e J/ Registration Number
J �72nonn, >�P 1 � "Address
el
4 ,Ji' 'Q�' Expiation Date
Signature / Telephone
SECTION 6;.WORI{ERS'COMPENSATION INSURANCE;AFFIDAVIT;(M.G.L.c. 152. §25C(6))
a„
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'.CONTRACTffJ�O,,R AP,PLIESfFO BUII D NG-PERMIT
I> �� LGGS /�b P� �!A
v as Owner of the subject property hereby
authorize < ' to act on my behalf,in all matters
relative to work authorized by this building permit application.
b
Si nature of Owner Date
SECCTION,7b:.OWNER UTII t•ORA012IZED-A GENT;DECLARAT"ION '
I, '4 � Ai ' Y 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.
Print Name � - i �
Signature of Owner or Authorized Agpt" Date
(Signed under the ains and enalties of r'u
ry-
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.
2. When substantial work is planned,provide the information below:
Total floors 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"