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The Commonwealth of Massachusetts Town of Mas <br /> U'r <br /> State Board of Building Regulations and Standards Building Depa nt JUN �} 2 �3Massachusetts State Building Code 16 Great Neck Ro orth• 780 CMR ----- <br /> APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING <br /> This Section For Official Use Only <br /> Building Pe umbe . Date Issued: <br /> Signature: I—o <br /> BuildingCommiuio Mlns or of Buildings Due <br /> SECTION 1.=SITE INFORMATION <br /> 1.1 Property Address: 1.2 Assessors Map 8c Parcel Number. <br /> 41 T n( )2uS ;[ 2e t-aT G 3 <br /> CLie( Map Nu be4- �ucel Number <br /> 1.3 Zoning Information: 1.4 Property Dimensions: Lot Coverage%: <br /> \00 f <br /> Zoning District Ropoaed Uu WArea(ab Frontage(it) <br /> 1.6 Building Setbacks(ft) <br /> Front Yard Side Yards Rear Yard <br /> Required Provided Required Provided Required Provided <br /> 1.7 Water Supply(M.G.L.c.40.§54) 1.5 Flood Zone Map 1.8 Sewage Disposal System: <br /> • Public 13 Private Q Zone Outside Flood Zone O Municipal 0 On site disposal system 0 <br /> SECTION 2.—PROPERTY OWNERSHIP I AUTHORIZED AGENT <br /> 2.1 Owner of Record: <br /> Na a(Print) Address <br /> 14 f <br /> re Telephone <br /> Authorized Agent: <br /> Name(Print) Address <br /> Signature Telephone ' <br /> SECTION3.—CONSTRUCTION SERVICES <br /> 3.1 Licensed Construction Supervisor: Not Applicable Cl <br /> Ws r2e,o 04 :Q63 <br /> Licensed Construenop Supervisor License Number <br /> Address <br /> Expiration Dam <br /> 4�srGS` <br /> Signuuro Telephone <br /> 0 3.2 Registered Home Improvement Contractor. Not Applicable 0 <br /> �� Cas <br /> Company Name Llcen- <br /> Addreu ExpirationDattel�p <br /> Si¢naturc T�IenMw. <br />