0005 SKERRY STREET - BPA-09-93 The Commonwealth of Massachusetts ;
!.y . .b ,; Board of Building IZcgulatiuns and Standards i
NII'NlCllIP
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Massachusetts State Building Code. 780 CMR. 7"' edition LItili
Building Permit Application To Construct. Repair, Renovate Or Demolish a Krrlsed.hoolho
One- -Fumilr [)trcitin•q
This Secti n For Official Use Only
Building Permit N mber: _ Date Applied: —_
Sisnature:
t d Conunusiuncr nspe i r Buildings Date
ECTION_ 11: SITE INFORMATION
IPro erty :address: 1.2 Assessors Mop & Parcel Numbers
XE,QKY
I.la Is this an accepted street? yes no Map Numher Parcel \'uuthrr
1.3 Zoning Information: 1.4 Property Dimensions:
I Zoning Dfttrict Propunr d Use Lot Area;sq to Frontage t it) .--_—
1.5 Building Setbacks (f )
Front Yard Side Yards Rear Yard
! Required Provided Required Provided Required Pnividcd
1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal On site dislwsal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 wn rtof Fecord:/
Name int) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building Owner-Occupied Repans(s) ❑ Alteration(s) ❑ Addition ❑�
Demolition Accessory Bldg. ❑ Number of UnitsI Other ❑ Spccity:_ --
Brief Description of Proposed Work':
I
f - -
� SECTION 1: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials) Official Use Only
1. Building $ 50d
I. Building Permit Fee. $ Indicate how fete is duun fined.
[I Standard City/•I'uwn Application Fee
E3.
lectrical $ QOO ❑Total Project Costa (Item 6) x multiplier x
� i
lumbing $ Q Q 2. Other Fees: S
4. Mechanical (HVAC) S
List:
5. Mechanical (Fire
Suppression) Total All Fees: S
Check No. Check Amount: Cash ArIoUnt:
o. Total Project Cost: $ 0 Q or 0 Paid in Full ❑ Outstanding Balance Due: ___-
SECTION 5: CONSTRUCTION SERVICES p
5.1 LLiicceeJns�ed Construction Supervisor
O/Z&— ���Gl e
5�/7/�lZK r mber G I'. au�m 1 ate
Name of CSL- I]older pc)see helow)Addr•. Desorpion
nrestricted (u U) 1i.M0 Cu. H )
estricted 1�C2 Fanuly Dwellme.M 1I
:uunn Only
RC esidenli:d Kaoline Cu�ann `Telephone wSesidrnuul \Yindno .aril Suhnm _
SF 12rsidrntial Solid i°uel liurnu)e \ 1plianrc In,).111,11 wni
U Keeidemial Demolition
5.2 Registered Itonl¢,Improvement Contractor(I11C)
HI C any Name or HIC Registrant Lune
Registration Nwnher
om
E.rpi atiun Dafe
Signature Telephone
SECTION 6: WORKERS' COMPFNSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed :Ind submitted with this application. Failure to pn,vide
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
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize _ to act on my behalf, in all mauers
relative to work authorized by this building permit application.
Signature of Owner Date_----
�s / SECTIION 7b: OWN'EW OR AUTHORIZED AGENT DECLARATION
1, SeW 1,7ager _ , 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.
Print :Vat ^42!�- .0OC
Signature of Owner or.Authorized Agent Date
(Signed under the pains and penalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered con(ractor
(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 730 CMR Regulations 110.R6 and I IO.RS. respectively
2. When substantial work is planned, provide information below:
Total flours area(Sq. Ft.) d00 th (including garage, finished basemen Napier, decks or porch)
Gross living area tSq. Ft.) Habitable room count
Number of fireplaces 8 Number of bedrooms
Number of bathrooms 12 Number of hall/baths
Type of heating sysiem �f///l Number of decks/ Porches _
Type of cooling system Enclosed Open — T --
3. "Total Project Square Footage" may be substituted for"Toad Project Cost'