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.. Coo �... .... .. _ �..�.._...__... ............ .. ...._.�.�. <br /> TW <br /> he Commonwealth of Massachusetts Town of Mas <br /> State Board of Building Regulations and Standards Building Depa nt JUN 0 9 2 D3 <br /> Massachusetts State Building Code 16 Great Neck Ro orth <br /> 780 CMR ' <br /> APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING <br /> This Section For OfHdal Use Only <br /> Building Pe umbe . Date Issued: <br /> Signature: IfA <br /> �"� <br /> Buildin CommissionerAnspectorofBuildings Date <br /> SECTION 1._SITE INFORMATION <br /> 1.1 Property Address: 1.2 Assessors Map&Parcel Number: <br /> 1 "T �t,)2yS 1 2e T <br /> ftn"z QP Map Number +, Varcel Number <br /> 1.3 Zoning Information: 1.4 Property Dimensions: Lot Coverage%: <br /> \OD � <br /> Zoning District Proposed Use Lot Area(af) Frontage(ft) <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❑ Private O Zone Outside Flood Zone O Municipal O On site disposal system O <br /> SECTION 2.—PROPERTY OWNERSHIP/AUTHORIZED AGENT <br /> 2.1 Owner of Record: <br /> Na a(Print) a Address <br /> 14 t <br /> whdre Telephone <br /> Authorized Agent: <br /> ame(Print) Address <br /> Signature Telephone <br /> SECTION 3.—CONSTRUCTION SERVICES <br /> 3.1 Licensed Construction Supervisor: Not Applicable O <br /> 404 1"2en <br /> Licensed Construction Supervisor License Number <br /> Address Expiration Date <br /> . , ,sr c- <br /> Signature Telephone <br /> 3.2 Registered Home Improvement Contractor. Not Applicable❑ <br /> ,2d&Z /SLR,j o Al Zk <br /> Company Name License Number <br /> 3 m . . ' >1 T-1417 S14L6¢ <br /> Adress / Expiration Date <br />