14 WHEATLAND ST - BPA 16-1273 ROOF The Commonwealth of Massachusetts "kr
� Board of Building Regulations and 9 Standards = k 71 / Massachusetts State Building Code, 780 CMR jgJ ed Slur 20 ' t
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Building Permit Application To Construc Repair, Renovate Or Demolish aV
One-or Two-Family Dwelling q Or
r\ This Section For.OM ial Use Onl
Building Permit Number: Date Applied:
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Building 011lcial(Print Name). Signature• Date
` SECTION 1:SITE INFORMATION'
L1 Property A^Li ND ST 5�?�E}q M 1.2 Assessors blap&Parcel Numbers
fu a/he i
1.1 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 it) Frontage(11)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required AProvided Required Provided
1.6 Water Supply:(M.G.I,c.40,554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2: PROPERTY OWNERSHIP!''
2.1 Owner'of Record:
�l'LIDC�t'I.t)ECI�
1141me(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building VI Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Pro osed Work-: E F P/� g O o,F L4A 171+ /VF lir
tgACi7 �;�YI�/' Sti/i✓/,/0P_ r a�cy is �s� - stii�c
zArl�/J/_ ie✓)o'F A/,5744w D2/P UtSiff 6tNA mg GG/ l —.e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
I1C» Estimated Costs: Offleirl Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical s ❑Total Project Cost'(Item 6)x multiplierllf c%O7?x
3. Plumbing S 2. Other Fees: S 1��
d. Mcchanical (hIVAC) S List:
5. Mecllanical (Fire S 'rota)All Fees:S
Suppression)
U Check No._Check Amount; Cash Amount:_
6.Tut:d Project Cost: S /7� Q A� 0 Paid in Full Cl Outstanding Balance Due:
Z IZOI a
SECTION 5: CONSTRUCTION SERVICES 7
5.1 Construction Supervisor License(CSL) 75 0 3 2 x
61(112 /�: "�to y C'S 0 7g3? License Number Espirutiun Uate
t Niune of CSL[folder List CSLType(see below)
115,Im�N T Type - Description .
No.and Street
14 ^'J/ O -� 7 L] U Unrestricted(Buildings u -to 35,000 cu. 11.
V J' 7 / R Restricted 1&2 R unify Dwelling
Z iay/ruwn,State,ZIP M Masonry
Roolin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
q�Z a— Z—.0,93 p 1 /�� / 1 Insulation
Telephone Email address U Demolition
5.211 Registered Home Improvement Contractor(HIC)
�7-CLt Pig- CONSYJf 41C 7`/ON HIC Registration Number Expiration Dale
IIIC ump:ay Nome or HIC Registrant Name
9 §5� I JX//v :5�r
No.acid Street Email address
5F1-/914 w-/ 030?9 ffldz-
CityiTown,State ZIP Tele hone
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.
Signed Affidavit Attached? Yes ..........❑ No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED W H EN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT'
I,as Owner of the subject property,hereby authorize
t9 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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
cunt Tied in this q plic.tion is true and accurate to the best of my knowledge and understanding.
f
Print Owner's or t xizcd Agent's Name(Electronic Signature) -- Date
NOTES:
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
%%ww mns,eov.'oco Infomiation on the Construction Supervisor License can be found at w+aw.mass.cov:'das
2. When substantial work is planned,provide the information below:
rotal floor area(sq. tl.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. tl.) 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 fur"f ut:d Project Cost"
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