18 WITCH WAY - BPA (003) The Commonwealth of Massachusetts
ary OF
Bo M
�- Board of Building Regulations and Standards
Massachusetts State Building Code, 730 CMR SMar
;Reviseed�Llnr 201
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family fhvelling
Chis Sect ortForOfficial Use n'l .
Building Permit Number:•'. Ste A ph di
•wilding Official(Pont Name) St �_, Date
SECTION l:SITE INFORMATION
1.1 r erty Wdress: ��� 1.2 Assessors Map&Parcel Numbers
L la 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 SetbacIts(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided. Required Provided
1.6 Water Supply: (M.O.L c.40,§54) 1.1 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ — Check if es❑ Municipal❑ On site disposal system ❑
sECTION Z:; PROP..ERTlG'O/WNERSIrjPt!
2.1 0,1-werl ay Jf ReS O
Name(Print) City,State,ZIP
No.and Street —�— Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKr(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Id Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ti
SECTION 4: ESTENLATED CONSTRUCTION COSTS
Estimated Costs:
[rem Official Use Only...
(Labor and Materials
I. Building S 7 L Building Permit Fee:S Cndicafe how fee is determined:
❑Standard.CityfiVtvnApplication Fee.'
2. Electrical S s—co ' r
❑"fatal Project Cost (Item.6)x multiplier x
3. Plumbing i 5Vj 2- Other Fees: $— ^ L�
1. Mechanical (IIV:\C) S D�J /¢ List: ( (�?�-h1
i. Mechanical (Piro S .
.Sii : ressiun) _ /U� Total:Ul Fees: ,S-
Chock No. _Check Amount: _Gosh Antunnt:
l'nfal Project Cost: S Z�j Q f 0 Paid in full ❑ Ontstandim 13alance Oua:
r
SECTION 5: CONS'fRUC('ION SERVICES
5.1 Const ucliun Supervisor License(CSL) .(7
t' / [<_�? L�nsa umber --- Gcpiration Date
Name of Ifolder -{ J
List CSL'Type(see below)
7 L 2k(16-tL i2(f.. Type Description
No. and Street
S�(-f� lye—, $1.
nrestricted(Buildings s u el JJ,ing cat. tt.
7� estricted 13t2 Family Dwelling
City/rown,State, ZIP Masonry
Routing Covering
indow and SI(I
olid Fuel Burning Appliances
sulationTele hone Emailaddress emolition5.2 Registered Hoome Improvement Contractor(H1C) poe 00
44 / HIC Registration Number Es arat n Uate
I lIC Company Name or IIIC Registrant Naxe
L
No.and Stfeet Email address
City/Town,State, ZIP ale hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 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 Issua9ce of the building permit.
Signed Affidavit Attached? Yes.......... Er No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO DE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, is Owner of the subject property,hereby authorize Ak,4-2ek
to act on my behalf, in all matters relative to work authorized by this building permit application.
Z 3
Print Owner's Name(Electronic Signature) Dale
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Lcontained
ring my name below, I hereby attest under the pains and penalties of perjury that all of the information
in this application is true and accurate to the best of my knowledge and understanding.
ner's ur Awhuri�al:\gant's N,rme(Electronic Signature) Date
NOTES:
I. ;\n 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\LU.L. c. I42A. Other important information on the HIC Program can be found at
www.ncui.aov/oca Information on the Construction Supervisor License can be found at www.mas .'a» dL
2. 11'1en substanti;d work is planned,provide the information below:
Toad floor area(sq. lt.) _(including garage, finished bascrncntlattics,decks or porch)
tiro;; livin urea(iy. d.) .-_ Ihbitable room count _
Nt nbcr or tiraplace.i Number of bedrooms
Numberorbathroumi -_--_--- _--— Numherofhalt'baths
- -------- --
I'vpc o[heating syitcm ----_—.- Nunabcrafdeck.,' pnrcltci
I}peofcaolin� ry<rcna __-_.__._ Encloied _-_ (lpcn
� t r,,t it I'nq.ct Syouo ni.ty he ;ub;nnrtal r,,r 'I'm.il I'mied _-