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1 MALL ST - BUILDING INSPECTION (4) , � . ,� I'hz Commonwealth oFMassachusctts - — CI'I'1' OF ;�� � l3oard of Duilding Regulations and S[andards S,�LG�1 ��`,���� Massachusctts Stare Building Code, 780 CMR Reri.cud.1/rir'?O!l 'L;�� l3uilding Permit Application To Construct, Repair, Renovate Or Demolish a �� One-or Twu-Funulv Dir�llrn,K �� This Section For OfT•' I Use Only — 6uilding Permit Number. Da Applied: L3uilding 017icial(Print N.une) Signawre ' � SECTION i:SITE INFORAtAT10N 1.1 Pproperty AdJress: 1.2 Assessurs Map& Parcel Numbers c /- d"`�\'`. �'•T'/• � I.I a Is this an accepted street?yes_ no Map Nwnber Parccl Number 1.3 Zoning Information: � 1.4 Property Dimensions: v�.'� {�'b��O.Ekr.rtsL %oning Districl PraposeJ U>u Lot Area(sy�t) Pronlage(�l) I.5 Building Setbacks(h) Front Yard Sidc YurJs Rcar Y;vd Reyuircd Providcd � Requimd Provided Reyuired Provided 1.6 Nater Supply:(M.G.I.c.J0,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zune: _ Outside flood"Lune? Munici ai n site dis usal s stem ❑ ('ublic� Privute❑ Check if ye P � P 7'. SECTION 2: PROPERTY OWNERSHIP� 2.1 Owner�of Record: �`�iL i�c� ;� _� — i►...,R �� ���.�v,n u..c...� � a�t zv N;mie(Prinq Cily.Statc.'l.IP � +��- e�'�r— `�1F�S'9`f �L,`7 iGe�w/ Nu.:md Strcet felephone EmaJ Address SECTION J: DESCRIPTION OF PROPOSED WORK3(check all that upply) New Construction❑ Esisting Building� Owner-Occupied Repairs(s) ffi. Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Speciry: Brief Description of Proposed Work` � T SECTION a: ESTIDIATED CO�STRUCTION COSTS ` Estimated Costs: Oflicial Use Only ILabur and �laterials� I. Duilding q �3p d o� I. Building Permi[Pee: E Indicate how fee is detennined: ❑Standard CitylTown Application Fee '_. [�7ectrical g ❑Total Project Cost�(Item 6)s multiplier .e_?\ 3. Plumhing 3 ?. Olher Fees: $ / 1. .Vcchunital 11I\'ACI 5 LisL• ` � 5. ,Vechanical ll'ire � .i'otal r111 Fees: 3 '. Su iressiunl � Chcck No. ChrcA AmuwiC C;uh :\muunC--- G. Total Project CosC 5 ��rj B� ❑ p�id in Full O Outstanding [3al:mce Due: __-_-_--- � SF.C'7'ION 5: ('ONS"fRUC'PION tiF:RV1C'F,S ' , � SJ Construction Supervisor License(CSL) � —3 3—� � d�A,�_ ' _�_'[iG:Q.t-' _� ��(l�_ � I.imnsc Numbcr I(�fnn�waJ.Aere Nanm u(C:SI. I IulJor �.a � ' � �(�s-�--QA .s..._ . �� ��� I.iu C�tiL�(}�pc(stc l�cluw) ��ir-�i"'(��i \ No.anJ Strccl — Type Descriplion �. i Unres�rictcJ 113uildin�s u' �0 35.00U cu. tl.) �� • r'`� �"°� 6 u"�-4i��- ��--��— N RcstricteJ 1&?Pamil D�rcllin� l il�/lo��n.Si;uc.ZIP �,�sL, M M.uunr � RC Ruutin Cuvcrin W'S N'indow and SiJin SF Solid Pucl 13urning Applianccs . ` ��- Zb�T� �i ,a � ,�tm � I Insulution ..cic honc lim,iil address � r.0 U Demolitiun SZ Registcred Ilome Improvemen[Coatractor(HIC) , I IIC C OII1PJi1)'Nl1011`0�I UC RCbISlf:llll N:IIt1C I IIC Rugistr:�liun Nwnbcr P.xpir;rtiun Ualc Nu.and Strcet Cmuil aJJrc.s Ci /Town, State,ZIP Telc hone SECTION 6:WORKERS'COMPENSATION INSURAIVCE AFFIDAVIT(M.G.L,c. 152.¢ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this atTidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached7 Yes .......... ❑ No.......,... ❑ SECTION 7a: OWNER AUTNORIZATION TO BE COAIPLETED WHEN OWIVER'SAGENTORCONTRACT A S R ILDIN T I, as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by his building permit application. .. L+t p ra..t[�`'6 ' s'^h�,t'at7'iGCs � '�. Pnnt O�oner s Name(Electronm Signuture) ate �'� 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 infonnation contained in this app�ication is true and acwrate to the best of my knowledge and understanding. Print O��ner's or AuthorizeJ Agent'x Nante U91ecVunic Signalure) n�t� NOTES: L �\n Owner whu ubtains a building permit to do hisiher uwn work,or nn owner who hires an unregistered cuntnctor (not regisrered in the Hume Improvement Contrnctor(HIC) Program),will nof have access to tha arbitration program or guarunty fund under \I.QL.c. Ia?A.Other imponant information on the HIC Program can be found at ��������P�.�>a.•����� u.:� information on the Construction Supervisor License can be found at �������,nia;<.��,��.11p_ ' \Vhen substantial wurk is planned,provide the inf'unnation below: Tulal Fluor arca�sy. tT.) _ �incluJing garaga, finished basement'attics,decks or purch) Gross living area�sy. tt.l___ _ Habitable room count \'umber uf lireplaces _----- Vumber uf bedruums �-- -------�--- V um her uf bath rooms ------------- ------------- �umbcruFhalf?baths 1'ypcofheatingsysrem .----------- �'umberofJrcAs� porches ----------- 1'�pe n(cnuling ,y stem --------- ---------------.-- En�loscJ _ Opcn ------ i. �Toiul Projee� Syu;�rc Foo�agc"may Nc subs�iiutcJ tiu"�('uta� Pruject Cust" �------ ---- � �� � I � � � � � � 'i _�----""- � � � �� � � ;, J ,..���� � � r� � � � � '' � � � � � � .� � � � � � � , � , � i ,�.��• ,����• - -�. , � � ta ��,.. ��� _ � �� o a , "— c�'] � If� , i �,,� � -� _ � _ __ _- -- - -- _ , ,�� r� c� - _.._ _ i •-- - -_ — -- °� � — �- -- -�z;�.�,..�,-��--- ---- _ _ � r= _ � _.. � � � ��i I� � I�1�J � � � � � � � � � � � � ' � � � � � ....,. - ��,, .. _ .- � � � � � ,. � I� �I I �. _ _ � , ,. . w �� , � , ,w . . . . � :� �� _ - - . .. � __ _ � I � � ���� ��� .� - - � � � . ------------------------------------------ - - mm _ _ __ _ ' � _ _ __ _ � m m ..... � �� w � � �- ' ; � � 3-0' � � �, a !% / � • ' i � • � 1� �1 � i ` � � . .. . � � .. . � I � �� ' . .. . . � �. uJ .. . . � � III � . � __'� . . . . . ,�-,� _ .``` �—��� � _ —ti _' ;\, w . �. . .� � � � � c� � � y- ` `�� � , .� r � ,�'' �� � � � � �—. 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