7 WINTHROP ST - BPA . y oo
i
The Conmwn"ealth of Massachusetts
Board of Building Regulations and Standards I t)R
``II'Nll ll'.V.fll
Massachusetts State Building Code. 780 C'MR, 7"' edition I IS
Building Permit Application To Construct, Repair. Renovate Or Demolish a Rrriard./am"11
� One-or Tit D)rrllin,q
1, _tVS
This Sect An F(J Official Use Only
Building Permit Number: ate Applied:
Si_nature: `� o
Building Commissioner/ Ins ertor of Bt din Dare
y
SECTION 1: SITE INFORMATION _
1.1 Prope kddrr��d O �r. 1.2 Assessors Map & Parcel Numbers -- i
I.la Is this an accepted streeett yes no Map Nunther _ P:ucrl \umher
1.3 Zoning Information; — !.4 Property Dimensions: - —
Zoning District Proposed Use Lot Area(sy (k) Frontage I It)
1.5 Building Setbacks(ft) ____
Front Yard Side Yards Rear 1 aW
i _. —
Required I Provided Reyuircd Provided Rcywred ProviJrJ �
1.( 1Vater Supply: (M.G.I_c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone- Outside Flood Zone? Municipal ❑ On site disposal c sicin ❑
Public ❑ Private ❑ — pa I T
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
w t of Rxcor d•
Nam- ; i o!) — ,�.� Address for Service:
�- 79 - 325- a 7�3
ignature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
l New Construction ❑ Existing Building ❑ Owner-Occupied Repuiis(s) Alteration(s) 5e' Addilion ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units 2 Other ❑ Specity:
Brief Description of Proposed Win k':_14jCn . F > _{�MOAot . tlh
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
�—1. Building $ 30 6 6(3 li 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
_I Electrical $ j 00 ❑Total Project Cost' (Item 6) x multiplier x
i
3. Plumbing $ 14 Sop 2. Other Fees: $ _
4. Mechanical (11VAC) $ NIA List:__
5. Mechanical (Fire $
Suppression) N �a Total All Fees: S —
Check No. Check Amount: Cash :\mnunt: _
0. 'Fotal Project Cost $ 3q jOQ 0 Paid in Full 0 Outstanding Balance Due:_ ___
SECTION 5: CONSTRUCTION SERVICES _
5.1 Licensed Construction Supervisor (CSL) --- .;�A.
License Number F:z pb:w on Dale
N'ante of CSL- I]older
List C'S I_'Pype(scr helow) _
4ddrces f• e Description
L t'nrestncted jup !o 3i.000 Cu. Ft.!
— R Restricted 1 2 Famih Mtelling
Signature .M Masonry Only
RC Residential Ruollne Cosertoe
Telephone \\'S RcsiJemial \y,nduw ,Ind Sidme
SF Rc,identi:d Solid Fuel Iiunnne
D Residential Demolition
5.2 Registered Ifame Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name - Registration Nwr.her
Address —
Signature Prlr
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c 152. § 25L(61) �
.y'ur rke,s ('umperr:3tic r. Insurance aftidtvit !Host hr. cr,n!oieted :inu wero;tted 1,11 pro ioe
this rt :avii will result in the denial of the i,su;. e e r f the buil•Lng permit.
:SieqeU :tfiida•:it Attached'? Yes .......... U iNc ........ L7
sECTno 7a[ OWNER AUi 10RIZA•r1 N TO ific Q't?NSI"LE i FD WHEN �
I OWNER IS %GENT OR CONTRACTOR APPLIES FOR BUMMING PERMIT
1
j -1C�ciq _�� as Owner of the subject property hereby
i authorize �, y�y�c +��"� to act c n m
� y behalf, in all m utei
relativ to work aurhorizF.d t this building permit ::pph%;a[ion. .p
_nature o_t Owner Date
SFCTI N 7b: OWNER[ OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
h,;SUAerncnir. and information on the foregoing application are true and accurate, to the best of my knowledge and
beha!I.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and renalues ofperjury)
NOTES:
1. An Owner who obtains a building permit to do hi %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. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations I MRG and 110.R5, respectively.
2. When substantial work is planned, pre•;ode the information below:
Total floors area(Sq. FL) _ _ (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 ha!f'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 Coat"
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' 30..--4—15"—�--24"
381, 48" 531"
139$
All dimensions size designations given are Ibis is an original design and must not be Desigted:4/26/2008
subject to verification on job site and ` released or copied unless applicable fee has printed:6/22/2008
adjostment to fit job conditions. be.paid or job order placed.
41109feO.ldt IFP 1 Drawing#: 1