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6 PIERCE AVE - BPA fii3-1 �- ISI c� ► Zi 4 ISSN - IL. The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code; 78.0 CMR S Revised Mar Mar 20111 . Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official•Use-Only . Building Permit Number: -D'ate A tied v , _'Building Official'(Print Name)' `. Stgtature,,.. - l D-1 SECTION 1:_SITE INFORMATION 1 1.1 Prop Addre 1.2 Assessors Map'&Parcel Numbers 1 1.1a 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:-PROPE�R7TY:OWPIEWS#111": Name(Pnot) T City,State,ZIP No.and Street - Telephone Email Address - - SECTION 3:DESCRIPTION OF PROPOSED.-WORK.z.foi ck,all thafapply). New Construction❑ Existing Building❑ Owner-Occupied ❑, Repairs(s) ❑ '1 Alteration(s) ❑ 1 Addition ❑ - Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify: PYJ Brief Description of Proposed Work : / '�/S✓I- f© - - - - B - SECTION 4:ESTIMATED-CONSTRUCTION COSTS" - Estimated Costs: Item rofficial Use Ouly �, Labor and Materials) <` 1.Building $ 03�y "I:'Bung Permit Fee: $ � Ihdicatehow-fee is determined:;, ❑ Standard City,town Application Fee- 2.Electrical $ ect . 3" ❑Total'ProjCost (Item 6)x multiplier x 3.Plumbing $ 2:".Other F.eesi':$` 4.Mechanical (HVAC) $ List: ' Y _ 5.Mechanical (Fire $ ;Total:qll Fees:$ Suppression) Check No. Check'Amount: Cash Amount: ^~ 6.Total Project Cost: $603 elo/ ❑Paid.in Full ❑Outstanding Due: _ " �' g SECTION 5:r.GONSTRUCTTON.SERVICES 5.1 Construction Supervisor License(CSL) iO 5! P n _,�) 9l•�,7 �� License Number Expiration Date - Name of CSL Holder ;V - List-CSL Type(see below) - YaLd No.and Street r+„Type, .„ -"c „;, Description ' n ® /D> R UnresRestricted 1 B Fami s u el 35,000 cu.4t. ' �'f— ! IJ R Restncted 1&2 Family Dwelling City/To",State,ZIP _ M Masonry - - _ _ RC Roofing Covering - - - :WS- Window and Siding q ,/!Q Is Solid Fuel Buming.Appliances 11,1l1 1 Insulation (Telephone Email address r D Demolition 5.2^Registered Home Im�p^r/ove entt^Contractor t(HIC) ./C 7 /yll( .V i I VYr HIC Registration Number. / Expi - HIC pan+Mate or HIC Registrant No.and Street Email address Gown,StatState,ZIP Telephone - ' -SECTION 6:.WORKERS'COMPENSATIOM.N LURAN�E A'FFIDA�_T.'(M.G.L.c..152.§ 25C(�):_ ' Workers Compensation Insurance affidavifmust be-completed and-submitted with this application.-Failure to provide this affidavit will result in the denial of the Issuance .the building permit_ Signed Affidavit Attached? Yes .......... No...........❑ SECTION,7a:'OWNER-AUTHORIZATION.TOBECOMPLETED-WHEN - OWNER'S AGENT OR.CONTRACTORAYP.I LIES I— BUILDINd PERMIT ` I,as Owner of the subject property,hereby authorize �fC - - _ to act on my behalf,in all matters relative to work authorized by this building perm[[application. Print Owner's Name(ElectronicSignature) - - - Date - - SECTION 76: OWNER'OR'AUTHORIZED;AGENT-DE.,CLARATION 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. - A•>r-� •-rY Print Owner's or Authorized Agent's Name(Electronic Signature) Date C - 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.eov/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" - -