96 WASHINGTON SQUARE EAST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECIAVERITYOF
Massachusetts State Building Code, 780 CMR INSPECTION 4L SMV8�
Revised Mar 011
Building Permit Application To Construct,Repair,Renovate Or Deutalish P3 2 A " O 9
One-or Two-Family Dwelling [U�V J
This Section For Official Use Only '
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Prop 1.2 Assessors Map&Parcel Numbers
� I >�i"P
1.1 a Is this an accepted stye es no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(fi)
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 OWNERSBIP'
2.1 Ownerof�N rd-
� 4F)t� 6n `
t Y/e
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : ��
3
G 't`
SECTION 4:ESTIMATED CONSTRUCTION COSTS g,
Estimated Costs:
Item Labor and Materials) Official Use Only
1,Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City iTown Application Fee
2.Electrical $ s
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) S List:
5.Mechanical (Fire S
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S _ ❑Paid in Full ❑Outstanding Balance Due:
m (�VLL-tE;oIC) ( -5, 1 , 1
SECTION 5: CONSTRVCTION SERVICES "
5.1 Construction Supervisor License(CSL)
99
License Number Exp do Date
Name of CS Holder
�? List CSL Type(see below)_
No.and 1 treet Type =-Description `
U Unrestricted uildin s up to 35,000 cu.ft.
�r►F F� �y� r J City/C R Restricted 1&2 FamilyDwelling
own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
�M I Insulation
Tele hone IEmail address D Demolition
5.2 Registered Home Im rovemen Co actor(HIC) I�I
S fb
HIC Registrnhon Number Ex iraC n Date
HI ny o HI ant Name
No d et
Email address
City/Town/Town Male,2 Tele hone
SECTION :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 o9hAttilding permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER kUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize G,&Z
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERt 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 applicat n. true and accurate to the best of my knowledge and understanding.
Print Owner's or Authonz d _ ent's Name(Electronic Signature) Date
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 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"
. 0 W 5 Q U •
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Zen Windows Boston LLC w 1 n ® o w a
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