4 MADELINE AVE - BUILDING INSPECTION The Commonwealth of MassachusettsR£C£IV£
Board of Building Regulations and I�t a MAL SERVICE5
CITY OF
' SALE,a Massachusetts State Building Code, 780 CMR' Revisedd Mar12011
} g PP Plort+`aYl �� P �` 59
Building Permit Application To Construct Re air,a Demo tsh a
One-or Two-Family Dwelling '
This Section For Official Use Only
Building Permit Number: Date Applied:
60
Building Official(Print Name) _ Signature Date
SECTION 1:SITE INFORMATION
i1.1 Property S1ddr Kk _ 2 ,� 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted 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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 t fRecord:,
�!
Name in -City,State,Z ZIP
No.an Street 6f-2,k - 2- It) —22z S
Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check a that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) 07 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building $ 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. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) �� D
��^+ License Number Exp do ate
Name of C L H der _ List CSL Type(see below)
T c - Description
Ad - U Unrestricted u to 35,000 Cu.Ft.
R Restricted 1&2 Famil Dwellin
gnature M Mason On
f _ �I RC Residential Roofm Coverin
Telephone 4! WS Residential Window and Sidin
SF Residential Solid Fuel Burning A pliance Installation
D Residential Demolition
5.2 Registered Ho to mp ovement Contractor(HIC) ([r�,
Registration Num er
HIC Co any r HIC t n
Ad Expir ton at
ature a ephone
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 Issuanc_9,dthe building permit.
Signed Affidavit Attached? Yes ..........E3 No ...........11
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
I, ��� + to act on my behalf,in all matters
authorize
relative to work authorized by this building permit application.
Date
Si nature of Owner
SECTION 7bi OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
I,
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
m
behalf.
A�
grin N e
to
.gna re of wne Authon
Si n d under the ains and penalties of P NOTES: "
1. An Owner who obtains a building permit to do his/her own work,or anvo-�er who hires not have access to the azered contractor
(not registered in the Home Improvement Contractor(H will(HIC) Program), _
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 I I0.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
gauge,finished basement/attics,decks or porch)
Total floors 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 Cost'