23A WISTERIA - BPA The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
(� pt�} Massachusetts State Building Code, 780 CMR, 7'"edition Wilbraham
" > 4y; g
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One- or Two-Family Divelling Ext 118
This Section For Official Use Only
Building Permit Nu er. Date Applied: 11
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Prope y Ad r ss:.- 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street'?yes -V' no Map Number Parcel Number
1.3 Zoning Information: L4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
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: ICI
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: U
Name(Print) - A-ffres/s-Tor/S/VeLrvice:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: -
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ LOtherFees:4. Mechanical (HVAC) $5. Mechanical (Fire $Su ression eck Amount: Cash Amount:
6. Total Project Cost: $ 0 Outstanding Balance Due:
V 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction up rvisor(CSL) 0
p License Number Expiration Date
Na o der List CSL Type(see below)
Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
Restricted 1&2 Family Dwelling
Signature J--C M Mason Only
/ U / a RC Residential Routing Covenn
Telephone WS Residential Window and Si din
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regis red om mpr Contractor(HIC)
HIC Compa Na HI gists V a e egtsiration tuber
Ican 4 6
Address
V V✓ Expiration Dale
Signature Telephone
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........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _
1 , as Owner of the subject property hereby
authorize _ to act on my behalf, in all matters
relative to work autherized by this building permit application.
Signature of Owner - Date
SECTION 7b: OWNER[ OR AUTHORIZED AGENT DECLARATION
\ ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. / —
L o
Print Name
Signature of Owner or Authorized Agent Date/ (/
(Signed under the pains and penalties of er u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
I (not registered in the Home Improvement Contractor(HIC)Program), will rrot 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 I I O.R6 and I IO.RS, 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"