wagner permit app p1The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two -Family Dwelling
FOR
MUNICIPALITY
USE
Revised Mar 2011
This Section For Official Use Only
Building Permit Number:
Date Applied:
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
'95 M%I.YdfT-1; 51;�—
1.2 Assessors Map & Parcel Numbers
Map Number Parcel Number
1.1 a Is this an accepted street? yes no
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
339 Sr 35
Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard -
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
r
'-7 3
SS I
1.6 Water Supply: (M.G.L c. 40, §54)
Public f Private ❑
1.7 Flood Zone Information:
Zone: _ Outside Flood Zone?
Check if yes
1.8 Sewage Disposal System:
Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' of Record: �f ��/� �f ,1 f
T)®5 P�'�iV � P-- pi D p-`Tf"'Ity. , i t-o i� / r �.0'1"` V� �(,1 d
Name (Print) City, State, ZIP
0'2,9 —9 b �-a bwa3 ' ergsypyAaOi t
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW (check all that apply)
New Construction ❑
Existing Building ❑
Owner -Occupied ❑
Repairs(s) ❑
Alteration(s) X
Addition
Demolition ❑
Accessory Bldg. ❑
Number of Units
Other ❑ Specify:
Brief Description of Prop sed Work2: Cb V ulig 1(-
?r.'r�
rt
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
(Labor and Materials)
Official Use Only
1. Building
$ 15
1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
❑ Total Project Cost' (Item 6) x multiplier x
2. Other Fees: $
List:
2. Electrical
$ ��
3. Plumbing
$
4. Mechanical (HVAQ
$ p
5. Mechanical (Fire
Suppression)
$
Total All Fees: $
Check No. Check Amount: Cash Amount:
1 0 Paid in Full 0 Outstanding Balance Due:
6. Total Project Cost:
$ 2 JD J-90