0014 PIEDMONT STREET - BPA-12-93 i The Commonwealth of Massachusetts OF
q / W
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code,780 CMR SALE
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Offipial Use Onl k- .-
w _ m
Building Pe = ® ---::: _, ate Applied
-Building Official(Print Name) .._._:g ...,'� - ._ Signatu _,^,.. -.'a"F
_ ,f-,- .. „_Dare
`.' >:SECTION 1:SITE INFO N-r
1.1 Property Add ess: 1.2 Assessors Map&Parcel Numbers
44 Pia rc-r�
Ll a Is this 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2;"PROPERTY OWNERSHIP,
2.1 Owner'of Record:
Name(Printy City,State,ZIP
I`I RoArrti€ N 1:�t-7 "6 —ICIOOX51
No.and Street Telephone Email Addrl
R=SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that a 1 ,!
New Construction ❑ Existing Building❑ - Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other 13K Specify: t'
Brief Description of Proposed Work : a
i
m
!' SECTION 4:ESTIMATED CONSTRUCTION COSTS2
IMMIS
Estimated Costs: e O
Item _, Official Usnly
Labor and Materials ma u -- .•
1.Building $ j SQ 0 1 Building Permit Fee $ t= Indicate how fee is determined
❑ Standard City/Town Application Fee r
2.Electrical $
❑Total Project Cost3(Item 6)x multiplier x '^
3.Plumbing $ 2 Other Fees $ ' , � G VOKL
4.Mechanical (HVAC) $ List —' •.
5.Mechanical (Fire -'"" "`�
Totaea
Su ression) $ n .,l All Fe $
Check No d Check Amount. "K�Cash Amount ''
6.Total Project Cost: $ i��C) ❑Paid in Full „^L,07,13 Outstanding Balance Due w
SECTION 5:;CONSTRUCTION.SERVICESi ,
5.1 Construction Supervisor License(CSL) CI.- S 2y CL
_Qk n^ UAV&1'\ License Number Expiration Date
Name of CSL Holder V
i List CSL Type(see below)
No.and Street Type -�__ `Descnpnon ^_' m
� 1 U Unrestricted(Buildings up to 35,000 cu.ft.
q
M P 1 /OVA(S A Restricted 1&2 Family Dwelling
City/Town,SIte,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
On SF Solid Fuel Burning Appliances
Q1 qZZ p-I S -" L� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
unn IAt.1t1 HIC Registration Number Expiration Date
HIC CConapaName�o'r HIC Registrant Name F{,/y
No.and Street Email address
P.gt2si„ /I11��ntq�
Ci /Town,Slale,ZIP Telephone
.. -_ �.,,....e.. a.... . .LL i-
,tSECTION 6:,WORKERS'COMPENSATION INSURANCE AFFIDAVITj(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 COMPLETED WHEN� ki 0,i
w � .„ -:-' OWNER'S AGENT-OR CONTRACTOR'APPLIES�FO jR BUILDING PERMIT .,
I,as Owner of the subject property,hereby authorize n O b-Q{ \(S[CV\
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print er's a(Electronic(ElectronacSignatar65 I Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION,
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained
in this application is true and accurate to the best of my knowledge and understanding.
7AUJ il
Mint Owner's or Authorize a(Electronic Signature) Date
ao---NOTES.n_. _.....
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 www.mass. og v/dos
2. When substantial work is planned,provide the information below:
Total floor 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"may be substituted for"Total Project Cost"