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39 WISTERIA ST - BPA "The Commonwealth of Massachusetts E�t�pNA Board of Building Regulations and Standards ,�NSP CITY OF Massachusetts State Building Code, 780 CNIR 1 ��pp of ` R vise .Llur 2011 Building Permit Application To Construct, Repair, Renovate Or[ I��hsh a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date A lie d Building Official(Print Name). ` Signuture- D: SECTION is SITE INFORNfATION L I Property Address: 1.2 Assessors Map&Parcel Numbers I.1a 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 11) Frontage(It) 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 es❑ Municipal❑ On site Disposal system ❑ SECTION2; PROPERTY OWNERSHIP' 2.1 Owner of Record: C.a i., b 6. t_( -S A f:0 .n M A �ie(Print) r-� City,State,ZIP —3 c W%,&re R..r'.A S- - 30 1 IS D 5 _1z t $ C( No. and Street Telephone Email r ddress SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Buildin caner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify: Brief Descrip�ti7on of P/roposed Work: S'—( /-4,) V J-0 di_ C,—Aa-1 G-� zz0 V`x SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Nlaterials I. Building $ + 0 ® 1. Building Permit Fee:$ Indicate how fee is determined: �. Electrical S ❑Standard City/Town Application Fee . ❑Total Project Cost'(Item 6)x multiplier x 3. Phimbing S 2. Other Fees: $ 4.Mechanical (FIVAC) S List: 5. Mechanical (Fire $ Suppression) total All Fees:$ Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: $ 00 0 Paid in Full 0 Owstandiru Balance Due: r SECTION 5: CONSTRUCTION SERVICES 5.1 Cmtstructibn Sulrcrvisor L�� to(CSL) Ct.y 11,3 1 l I ' —s License Number Expiration Date Name of CSL Holdera I v t p � f • 1^f List CSL'fype(see below) No.;md Sueet nA Type - Description rF©,A b Ca,AY C A � � q (�� D Unrestricted2 Family (Buildings u el ing co. It.) R Restricted 1&2 F;unil Dwelling Citylrown,State,ZIP NI I'vlasomy RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances :3-A I Insulation Telc hone Email address I D Demolition 5.2{ Registereed^Home Improvement Contractor(HIC) , D 08 l t l--.O..r✓is t, Cei z er HIC Registration Number Expiration Date fllc Cumpan Nmne or f11C fiegislrant Name Email address�/?8 �31 �'r�3`t City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(ttNLG.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.PERAHT' 1, 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 contained in this application is true and accurate to the best of my knowledge and understanding. r I;K�- 5-- -7 -9 Print Owner's o \ horizcd Agent .Name(Electronic Signature) Date NOTES: I. 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 nal have access to the arbitration program or guaranty fund under ibLG.L.c. I42A.Other important information on the HIC Program can be found at www.nutss.wv'oc:t Information on the Construction Supervisor License can be found at rwvw.mass-�•ov/dps �. When substantial work is planned,provide the information below: "total floor area(sq. RJ (including garage, finished basement/attics,decks or porch) Gross living area(sq. 11.) 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. '"rood Project Square Footage"may be substituted for"Total Project Cost"