50 WINTER ISLAND R0AD - BPA 12-389 �LJ _'�, -- ---- The C'ummunwealth of Massachusetts -
yl Board of Building Regulations and Standards CI"I'Y OF
Massachusetts State Building Code, 780 C'NIR SALLAI
Building Permit Application To Construct, Repair, Renovate Or Demolish a RerisrJ.l Lu•_'ill l
One-or Tivo-FumilY Uuvelling
This Section For Offlc'dilUse Only
Building Permit Number: Dat Applied:
holding Official(Print Name) Sigrtatare Dale
SECTION I:SITE INFORAIATION
\, I.1 Property Address: 1.2 Assessors blap& Parcel Numbers
fl
I.I a Is this an accepted street?pest'_ no_ Map Numlxr Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed llse Lnl Area(sq tl) Frontage(fl)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.1.c.40.§SJ) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check:1--1 Municipal Cl On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
/�u'c/ntal 7i)sslirr r/z PERt�oD�` IA, 61760
None(Print) City,Slate,ZIP
g>s-6- T�tsS�'tG�OcoNzc�r
Nu.and Street Telephone F.mail Address
SECTION J: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Spccit'y:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and \laterials) Ofllcial Use Only
I. Building S I. Building Permit Fee: S Indicate how feeds determined:
2. Electrical S - ❑Standard City/Town Application Fee
❑Total Project Cost'(item 6)x multiplier .x
i, Plumb%jechanic S 2. Other Fees: S
J. \lech:mical lilt'.\C'1 S List:
_+. \lechanic;tl
tiu t trtsiiunl Total :\II Fees:
n Total Project Cost: S Check No. _--Check:\mown: - ------ Cush \mount:
❑Paid in Full ❑Outstanding Balance Due:
1
SECTION 5: CONSI-RUCPION SERVICES
5.1 Construction Supervisor License(CSL)
- ----------
------------- --
I r I censc Number Fvpiration Date
x\` Name of C\I. Iloldcr
List CSI.
No. And Street
�^ /u�-.� �� � (II hvestricteJ I IArilJin15.U110 cu. fl.)
PG� O Y � R Reelricted I&I Fainill MWIlin•
C its"fowl.Stale.LIP M Nlasolilry
RC Roofin Coverin
WS Window and Siding
SF Solid fuel Burning Appliances
�78 �7(o�2G/ T1(✓7�C0/YCaS�RI I Insulation
1'cie hone F:nlail address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Fspiraliun Uutc
I IIC Company Nunes or I IIC Registrant Name
No.;old Sued Finail address
City/Town, State,ZIP "retc hone
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... O
SECTION 7a: OWNER AUTHORIZATION TO HE 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.
.�?riot Owner's Nwne(Flectmnic Signature) Date
TI N 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
B e t I» ire be`(o�v,` here y. est and r the pains and penalties of perjury that all of the information
coat ne in this a I' on i and cur to to the best of my knowledge and understanding.
0 3 I
Print Owner's or:\uthori cd Ag it's Name(Fiectronic.Signature) utc
NOTES:
I. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(nest registered in the Hume Improvement Contractor(HIC) Program).will no have access to the arbitration
program or guaranty tund under NI.G.L.c. 1 J'_A.Other important information on the HIC Program can be found at
\r\r\l 111,11, ,% ,�,A Information on the Construction Supervisor License can be found at�%ks\%.ni.l.:
? When substantial work is planned, provide the information below:
Total floor area(sq. R.) _ _____(including garage, finished basement attics.decks or porch)
Gross living area(sq. it.I Habitable room count
\umber of fireplaces.--- - ---- -- -- - Number of bedrooms - " -- -
Number of bathrooms _. -- Number of half haths
I)pc of heating iy item Number of decks, porches _
I)pc of cooling st 53en1 _ I�nelasdd Open
i. "l-ol;ll Project Square Footage-III;Iy he substituted for"fo(al Project Cost'