0004 MOULTON AVENUE - BPA-10-348 11 The Commonwealth of Massachusetts
, Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C 7`'edition ALEM
ReOF S Jan Mry
4 Building Permit Application T o tract,Repair enc vate Or Demolish a 1, 2008
1J1 One-qi Two- mily Dw ling
Oik'Sidtion " pT) tal'U"Only
Building Permit Number:
Signature:
Building Commissioner/I '*cctorofB gs, Date',."—rT
SECTIO 1SlTE-INFORMATION
1.1 Property ass 1 ` C 1.2 Assessors Map&Parcel Numbers
1.1�an accepted street?yes,___ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District, Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system [I
SECTION . PROPERTY OWNERSHIP'
2.1 O ner oft cor As
/L// t/Llf(� ele/L
Name(Print) Address for Service:
Signature Telephone -
SECTION 3:DESCRIPTION OF PROPOSED Wl RW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: EST_IMATED`CONS.TRUCTION COSTS
Estimated Costs:
Item Labor and Materials ',`';; 'Official Use Only
1.Building $ 1. BtiildingPerrnitFee:$ - Indicate how fee is determined:
2.Electrical $ ❑Stan ard,City/Town Application Fee -
❑Total.Prolect Costa(Item 6)x multiplier x
3.Plumbing $ 2. OtlierF�es: $
4.Mechanical (HVAC)
5.Mechanical (Fire
Suppression) $ Total All Fees: $,
Check No Check Amount: Cash Amount:
6.Total Project Cost: $ Y�, ❑paid in Full ❑,Outstanding Balance Due:
SECTIONS CONSTRUCTION SERVICES
_ �, <_...
5.1 Licensed Construction Supervisor(CSL)
M ( (a e L \\ ,-to 6—' License Number Expiration Date
Name of CSL-Holder- V� �1 List CSL Type(see below) y
6 - l i.�GGc� �t I) PiSC Qe
Address T. :rDeBori lion
t U I•Unrestricted(up to0 Cu.
R Restricted 1&2 Family
Dwelling
Signature t�i� M Mason Only
7F' ,S J 7 3 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
IF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registere Hqr� pe I rpprovement Contract r(HIC) jam. �,,S_u
1/n�_r
HIC Co ,Name or HIC Reg t t me // /� Registration Number
Address
L�t w ,�,,�j i �• '� �i� ,, �� ` � �k.7��.(�'��3 Expiration Date
Signature / Telephone
SECTION 6 WORT I* COMPENSATION INSURANCE 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 of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
=SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETEDMMIEN
G OWNER'S AENT,OR RA CONSCTOR1APPLIES�FOR BUILDING PERMIT
I 1 5,e-6 4 �Pc (�/ as Owner of the subject property hereby
authorize �71 1 A J, �� r� to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner - Date
SECTION 76:.OWNERt QR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
' L 1.
Print Name �> >t
Signature of Owner or Authorized Agefitt Date
Si ned under the ains and PS,nalties of eriu
1. An Owner who obtains a buildingpermit to do his/her own work or an
p , owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I MR5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"