1-3 NAPLES RD - BPA-16-200 The Commonwealth of Massachusetts. RECEIVED
\ Board of Building Regulations and Standard's ECTIONAL SER ICE§ITY OF S
a Massachusetts State Building Code, 780 CMR' SAMar42011
O Building Permit Application To Construct,Repair,Renov�fpe��t arAgisA
One or Two-Family Dwelling
N This Section.For Official Use Only
Building Permit Numbers Dat plied:
31-s
1 Building Official(Print Name) Signature,. Date
:'SECTION 1:SITE INFORMATION .
1.1 Properly Add,Cpss:� \ 1.2 Assessors Map&Parcel Numbers
l.l a Is this an accepted s eet. 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(it)
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 yes0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSftIP1
2.1 Owner SRecor
n
Name(Print) City,State,ZIP
}, y
No.and Street " Telephoned Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK?(check a that apply) "
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) 01Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units er ❑ pecify
Brief Description of Proposed World:
s
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
l.Building $ ,� 1. Building Pe Fee: $ —trrdicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Feel, _
❑Total Project Cost;(Item 6):x multiplier ' ,x
3.Plumbing S 2. Other Fees: S
4.Mechanical (FfVAC) $ List:
5.Mechanical (Fire
Suppression) S Total All Fees $ >.
Check No Check Amount - Cash Amount
6. Total Project Cost: $ ❑paid'i t Full - ❑Outstnndmg Balance Duet"
�rnIn't i.- 3li s
l = SECTION 5: CONSTRUCTION.SERVICES '
5.1 Constructil nSuperviso ense(CSSL)
Lic nse Number Expir ti Date
Name ofCSL Holde
List CSL Type(see below)
o.and Street p / Type Description
N
1[t'/l _ - U Unrestricted(Buildings u to 35,000 cu.ft.
lqq �/ R Restricted 1&2 FamilyDwelling
City/Town,gtatte,21P
M Masonry
RC Roofing Covering
WS Window and Siding
.� SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement C ntractor(MC)
HIC Registration Number Ex ra' n Date
nl a o strai Name
No. Sttrr t Email address
Ci /Tow((n,State,ZIP Telephone
SECTION 6: WORKERS'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 Issuan of the building permit.
Signed Affidavit Attached? Yes .......... 6 No ...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT-
1,as Owner of the subject property,hereby authorize +IPSWzMar:
to act on my behalf,in all matters relative to work authorized by this bui ding enn application.
Print Owner's Name(Electronic Signature) Date
SECTION 76i OWNER'.ORAUTHORIZED AGENT DECLARATION
By enterin m name below,I hereby attest under the pains and penalties of perjury that all of the information
contain gpli on is true and accurate to the best of my knowledge and understanding
1
Print er or A onze Agent's Name(Electronic Signature) Date
NOTES.
1. An Owner who obtains a building permit to do his/her own work,or an 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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at vnvw.mass.gov/d 11_s
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"may be substituted for"Total Project Cost"