25 WISTERIA ST - BPA NtTs 22S-5
The Commonwealth of Massachusetts INS EC RE�j
ICES
R
' Board of Building Regulations and Standards �W�E
Massachusetts State Building Code,780 CMR Revised Mar ER
011
Building Permit Application To Construct,Repair, Renovate Or Demolish � APR 21 A S 4 9
One-or Two-Family Dwelling
This Section For Official Use Only
M Building Permit Number: Dat pplied:
( Building Official(Print Name) Signature Date
L I SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
25 LJ,s1 er,
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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ — Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
^n4L cl le L-x U N I r _s e r. NkA cal'i-7 o
Name(Print) City,State,ZIP
9,5 LJ,5la.rv. -5l. �7$-57$-9K7t7 to a o�eur,i @ co.,c�sl_noF
No.and Street Telephone J Email Ad ester s
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Erl Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': $ g -rp rn, Felon
rJ t 111, rcn I a ell d l II r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ >i 1 ci r60 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ D ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 0 2. Other Fees: $
4. Mechanical (HVAC) $ List
O
5.Mechanical (Fire
Suppression) $ O Total All Fees $
Check No. Check Amount. . . Cash Amount:
6.Total Project Cost: $ I I q�I] eo ❑Paid in Full ❑Outstanding Balance Due:
I. �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
_ �� Li
Ot S 11r N txe13S
N
O � vim^ License Number Expiration Date
Name of CSL Holder U
List CSL Type(see below)
No.and Street Type Description
2�I'7 Unrestricted(Buildings u to 35,000 cu.ft.
Hf ^el't9'� /wj' R Restricted )&2 Family Dwelling
City/TowiV,State,ZIP M Mason
Ty
QUI RC Roofing Coverin
L WS Window and Siding
L/ C SF Solid Fuel Burning Appliances
]nsulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I'7 3 5is12 3151 1
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
1191 AA'ass f) tn�o (cJ rail roo�
No and Sieee,t
Arll^ l , /H, ca i l b (�S�O`�1( "753Fi Email addres
Ci /T�ov ,State,ZIP 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 .......... 0-' No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize P--A � 0 5,11,v.n
to act on my behalf,in all matters relative to work authorized by this building permit application.n
Ja.Q. 01-ay y SeZ .SI4ACA ntr-J t/ 2 ) /5-
Print Owner's Name(Electronic Signature) u I 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
contained in this application is true and accurate to the best of my knowledge and understanding.
IY 4 - 1 N Ljt_F 1-
Print Owner's Authorized Agent's Name(Electronic Signature) Date
NOTES: 5;
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
)LAA ss. ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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"