The URL can be used to link to this page

0031 WASHINGTON SQUARE NORTH - BPA-11-119 V The Commonwealth of Massachusetts �- Board of Building Regulations and Standards CITY WMassachusetts State Building Code,780 CMR, 7 s edition ReOv s d January Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling is ecfion For Official Use"Only Building Permit Number: Date Applied: Sgnature � � o :Building Comnii'ssioner/Inspect f$a_ildmgs - D'ate;`;"' ' �. ,:SECTI©N1:SITEtI1VFORM'ATION 1.1 l Property Address. / ,/.. 1.2 Assessors Map&Parcel Numbers ?.la 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 OWNERSII10t 2.1 wner'o Record• J ,,c Name(Print) Address for Service: Sigr- Telephone - SECTION 3:DESCRIPTI,bN OF PROPOSED'WORK2(check all that apply) New Construction ❑ I Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units - Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only, 1.Building $ l: Buil"dingPermitFee. $ Indic'ate how fee is determined: 2.Electrical $ ❑Standard'City/Town Application Fee ❑Total-Pro48ct Cost'(Itern'6)Yc multiplie_r x 3.Plumbing $ 2 ,Qtlier.Fees:,$ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire Suppression) $ ,Total All;Fees $' �!t Check No. Check Amount: . Cash Amount: 6.Total Project Cost: $ ( J O paid in Full 0 Outstanding Balance Due: SECTION 5CONSTAUCTION;SERVICES 5.1 Licensed Construction Supervisor(CSL) �� /. M (C a e.L (�' \ . r-6L� License Number Expiration Date Name of CSL-Holder V�- List CSL Type(see below) V i�yo� L� U PAS --I-� , T. ,%'S. 'D"elscri tion Address 7 � U Unrestricted u to 35,000 Co.Ft. �� R Restricted 1&2 FamilyDwelling Signature - �, / M Mason Only -7�"7 �z S 3 RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Re 'stege H e I rprovement Contragt r(HIC) �d _ 4 C i HIC Cotppnny, " or C Reg t me Registration Number /GCS; Address,-� � � _ 7k 7q`/ �,-, Expiration Date Signature / Telephone 7— 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 Issuance of the building permit. 1 Signed Affidavit Attached? Yes .......... No...........❑ "SECTION 7s: OWNER AUTHORIZATION;TO 13 CbMPLETED WHEN OWNER'S AGENT OR CONTRACTORAPPLIES lk BU1L".DING-PER1yIIT. 1 as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized b, this building permit application. Signature df Owner 6 Date 5EpCTION,7b OWNER1 O,R AUT;HORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and ihformatio on the foregoing application are true and accurate,to the best of my knowledge and behalf c- l Print Name Signature of Owner or Authorized AgAt Date '#1 (Signed under the pains and penalties of r'u .. 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.R5,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 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"