0008 RAWLINS STREET - BPA-10-86r—
F 1a
The Commonwealth of Massachusetts
w Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'"edition
u� Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a !tom
One- or Tiro-Fmnih Du elling
This Section Fo Use Only
Building Permit Num r: Date p lied: /
Signature:
Building Commissioner/ tar of Butidin e -
SECTION 1: E ORMATION
I.I Property Addrepss: 1.2 Assessors Map& Parcel Numbers
8 R0.uJItns S+.
I.I 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 R) Frontage(R)
rsignatwe
ng Setbacks(R)
Front Yard Side Yards Rear Yard
d Provided Required Provided Required Provided
Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
'of Record:
D /' ✓ A/ddress for Service:
tp/- 5D5—G707
Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
Ne"io, l Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
DeAccessory Bldg. ❑ Number of Units_ Other ❑ Specify.
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
J. Plumbing S rdi 2. Other Fees: S
4. .Mechanical (HVAC) S ,dj List:
5 Mechanical (Fire
S Total All Fees: S
Suresstoo
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S a21 coo ❑ Paid in Full ❑Outstanding Balance Due:
�/ 7 � 309- � 70 -7
SECTION 5: CONSTRUCTION SERVICES
5.1 `Licensed Construction Supervisor lCSL)
License.Number Expuauo Dute
N;Imr ul'CSL- HplJer List CSL T Ypt I.cC below)
-O (7CJIF� 1 T I Description
Address
O UnresRestricted
1 u to Family
D Cu. Ft.
R Restnctrd Ih2 FamJ Dwellm
5r nmu i Yt Nawn Onl
�5 RC
f — Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
i Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 Issuagee of the building permit.
Signed Affidavit Attached? Yes..........d No........... C3
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. / ✓ Q�
Print N rl
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of r
NOTES:
I. 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 W 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 I IO.R6 and I IO.RS, 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 halfbaihs
Type of heating system Number of decks/ porches
Ty pe of cooling system Enclosed Open
1. "Total Project Square Footage' may he substituted for 'Total Project Cost"