16 WITCH WAY - BPA The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards
MUNICIP:\LI'fl'
Massachusetts State Building Code. 780 CMR. 7 1hedition USF
W Building Permit Application To Construct. Repair, Renovate Or Demolish a Rei oed home',
j� One- or Two-Fanri/v Dwelling
!. _rx)S
This Section For Official Use Only
Building Permit N mber. Date Applied:
Signature: / e if
ut Commissioner spector of Buildings Date
SECTION I: SITE INFORMATION
1.1 pro re 1.2 Assessors Map & Parcel Numbers
Ma Number Parccl Numhcr
I.1 a Is this an accepted street? s_ no_ p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sq tl) Frontage 011
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provtded Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40.3 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yesO
y SECTION 2: PROPERTY OWNERSHIP
of [
2.1 ��t � • �Gc L®� �
me Print) A s for rvtc
S nature Telephone
SECTION 3: DESCRIPT ON OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Speci'y:
Brief Description Vt P pPoised Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building Permit Fee: $33_Indicate how fee is determined:
1. Building $ 19t9U ❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ Ltst. q��
5. Mechanical (Fire $ Total All Fees: $ 33.
Suppression)
Check No. Check Amount. Cash Amount:
6. Total Project Cost: $ !� aV-0 aid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL- Holder
List CSL Type(srr below)
Address Type I Description
U I Unrestricted tup to 35.000Cu. Ft.i
Signature R I Restricted I&.'_ Family Dwellin
M I Masonry Only
RC Residential RoofingCovering
Telephone \VS
Residential Window and Sidra
SF I Residential Solid Fuel Burnin A chance liwallauuu
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
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 it) 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 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 authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I. ,as Owner or Authorized Agent hereby declare
that th .statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of ner or Authorized Ag nt Date
(Si ned under the sins and penalties ofperjury)
NOTES:
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115. 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 cowling system Enclosed Open
3. 'Total Project Square Footage" may be substituted for"Total Project Cost"