1 MALL ST - BUILDING INSPECTION (3) �� �� � ��f
� � �� tF °'°
,� The Commumvealth oF Mnss.ichusetts
,.. ° � Bo�rd of Buil�ling [tegulatious and Standards CITY UF
� btassadlusetts State Building Code, 7S0 CbIR SALE�I
�� 3 ` ��Y7 ' Rzvised Mar 201!
,��" Building Permit Application To Construct, Repair, Renov,t�e Or Demolish a
One-or Tivo-Family Dtive!ling � �
� `: 'Chis Sect't,on,ForOFficial Us nly ' '
Building Pzrmit Number: - Date App d>;
���•n,�. u-�--r �.� ' ` ,3 �y'
` Building Officiaf(Pnnt Nimz) , ., �. -S�gna e .-: � Date.�
SECTION L• SITE INFORi�1A O .
� 1.1 Property Address: L2 Assesso i p 3c Parcel Numbers
�tl..t eS �..v � 'Z�
t.t a [s this an accepted street? yes_ no Map Nu Parcet Number
1.3 Zuning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 E3uilding Setbacks (ft)
� Front Yard Side Yards Rear Yard
Required Provided Rzquired Provided Raquired Provided '
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flaod Zone Informatiou: 1.8 Sewage Disposal System:
Public ❑ Private ❑ Zone: _ Outside Flood Zone7 N�unicipal O On site disposal system ❑
Check if esO .
" , SECTION 2:;'PROPERZ'Y OWNERSHIPL :,
2.�1 ')Owner�of Record: . V� ��{ �^�
14b Ca C34'T � �� L� ('L) f cC. �AC.Iy'Un 1 '" ` [� Q � � �V
Nama(Print) � Ciry,Statq ZIP �j ` ' ^
1 [.L/1, y� �� �i Q'�rp �y�y'�lo 7 / t�n9 L�(J 4d t� t�f l lL ,� GP��CCl V'f
No.and Street . Telephone Em Adress
SECT[ON 3: DESCRIPTION OF PROPOSED WORK'(check all that apply}
New Construction ❑ Existing Building ❑ O�mer•Occupied � Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demofition ❑ Accessory Bldg. ❑ NumberofUnits Other ❑ Specify:
�. E3rief Description of Proposed Work2: (�.t�- S � .i.
�aT�� f3,bTe.c cZ�caw� iZ� hac� � �'�
SECTION a: EST[�L4TEB CONSTRUCTION COSTS
[tem Estimated Costs: Offieia! Use Only,.,
Labor�nd blaterials
I. Buifding $ L Bwlding Permi[Fee: � Tndicate liow fee is determined:
�. Eh:ccric;il $ ❑ Standa[d City/`Cotvn Application Fee I
" ❑"Cotal Pioject Cost'(Item.b)x mu(tiplier x
3. Pfumbin; S 2. Other Fees: �
L \Izch:u�ital (tfV:\C) `S Lis't:
5. :\(eehanic�l (Fire $
Sii � rc>siun) �Cutnl:AII Feas:$
— — Ch�cl.No. Check e\utount:__Cash r\muunt -- __--
� �. f'ot:�l Prnjcct Cust $ � �9 .f`JLJL�r� O I'nid in E_uli-- --❑ Outshinding Ilal;�nco Dn�: I
' - ---- ---- -- ----
_ �
srcr�ov s: covs�riiuc�riov s�avicH:s
5.1 Constructiun Supervisor License (CSL)
Licensn Number G.epiration Dute
N.�mc uf CSL Ituider
List CSL Type(see balow)
No. nnd Street 'TyPe . � � � Description �
U Unrestricted Duildin s u to 35,000 cu. It.
� R RcstrictcS 13c? Fumil Dwellin
Ciry/Town, State, LIP �I \�lasonr
' RC Raufin Coverin �
NS �Vindow nnd Sidin� �
SF Sulid Futl [3urning Appliances
[ Insulation
"I'cla hona Email address D Demolition �
5.2 RegistereJ Hame fmprovement Contrnctor(ki[C)
FI[C Ragistration Number E.epiration Uate
I IIC Company Nmne or FIIC Registmnt Nmne
No.and Street Einail address
Ci /Tuwn,State, ZIP ?ale hune
SECTLO�V 6: WORKERS' CO�IPEYSA'fION [NSURANCE 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 oFthe [ssuance of the building pertnit.
Signed Affidavit Attached? Yes .......... ❑ No ........... 0
SECTION 7a: OWNER AUTHORIZATION TO BE COhIYLETED WHEN
OWYER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PER�'[[T
[, 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.
Print Owner's Nrunz(Elactronic Signature) n��e
SF.CT[OY 7b: OWNER� OR AUTHOR[ZED dGEN'C DECLARAT[ON
By entering my name below, [ hereby attest under the p�ins and penalties of perjury that all of the information
contained in this npplication is true and accurate t t e be my dge and understanding.
2��� �zz l �-� -��,t, �i t� � �3
t'rint Owner's or Authori�ed:1;ent's Y:une(Elzctronic Sig�mture) Date
NOTES:
I. An O�vner whu ubt�ins a building permit to do his/her uwn work, or an owner whu hires nn unre�istared mntracror
(nut re�istere� in the Houie Improvemznt Conhacwr(H[C) Program), will �mt have access to the arbitration
program or guar�nty tund under i\LG.L. c. Id2A. Other important infurm:ition on tha H[C Progrssm can be found at
���v�v.m:us.��uv ora Infoimation on the Construction Supervisor License can be fuund at�r�vw.m:us.+�����_dL
2. \Vhen subst�nci.d work is planned, provida the information bzlow:
To[al tlour:trea(sq. 12J-- — _(including g:�r:ige, tinishel b:isement/;ittic,, dccks or porch)
Gro;, living:u'c�(sy. ti.l _ _ Habitable rvum cowrt
Niunbdr ut tir�placc�.----- — Numbtr of be�h'uoms -- -----
Vum6�ruFb�throoins Numberofh:ilEb:uhs — -- —
—---- —
f}'pc of li�:iting syst�m - ----- .---. — �wnhtr uFdack,/ porch�. ---_ ------
I�}�pa of eoolin�� sy;t�in 6:ncloscd C)pcn _ ,
{. "f�nt:d Pnij�ct tiqunra Po�x;t,�" ucry bc iubititut�J �:�r�'I�n�.il f'rujcd (b;t" --
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wall
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OR AS NOTED '
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