7 WITCHCRAFT RD - BPA L� The Coinmotnvealth of Massachusetts INSPE TIONAL SERVICE
Board of Building Regulat ons and Standards CITY OF
Massachusetts State Building Code, 730 CNIR 2015 P
IAd tr IlRi/?
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dlvelling
This Section For 0 cial Use Only
^^ Building Permit Number: ,ate Applied:!
Building Official(Print Name) _ Signature Date,
SECTION 1: SITE INFORMATION
1.1 Property Address: n Q= 1.2 Assessors Map& Parcel Numbers
l.I a Is this an accepted street?yes_ no b:ap 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: 1.3 Sewage Disposal System:
Public ❑ Private❑ Zone: _ Outsice Flood Zone?Check if es❑ Municipal ElOn site disposal system ❑
SECTION2:, PROPE2TY'OWNE1 IIPV
24 O nerro Recygrd: oid �C>
i
Name no() Ciq,State,Z�
aj
No.and Street Telephone Email Address
SECT ION 3: DESCRIPTION OF PROPOSED WOR.W'(check all that apply)
New Construction ❑ Existing Buildin Ocvner-Occupie . Repairs( Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Speci
fy::
Brief De cription of Proposed Wor.<':
Z e- CA/UdA V - f6L�C-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
RemJEEstimjosrt:s Official Use Only.,,
Labor
I. BuiS I. Building Permit Fee: S' rndicdte how fee is determined:
2. EleSC Standard.City(rown•Application Fee
CITotal Project Cost (Item 6)x multiplier x
3. PluS — 2. Other Fees: S
1. ,MecVAC) 3List:re $- Ibtel All Fees:-SCncck Nc. (Beck Amount:
f MCnit: S --
�V t7 I ii,l in Pull ❑ OntsCtnding llahtncc I?iw:
tYIA�L�D SI I
SEC'riON 5: CONSTRUCTION SERVICES _
5.1 Construction Supervisor License(CS[,) /���� ���—
License Number Expiration Date
Name orCSL Ilulder
k� u p MVr+✓ y=--- --- List CSL Type(see below)
No. and Street '`n- FYI Type Description
• - Q p 1 p ry /►J �— U Unrestricted2 Pii(Buildings u el ing cu. t't.
W`YC`-'v_��\`t��'"`"'��t�tXCC R Restricted ISc? F;nnil Dwelling
City/Tome,State, "!_IP M Nlasonr
RC Rooting Covcrin
WS Window and Siding
C, SF Solid Fuel Burning Appliances
Y-7l9t�S'� do I Insulation
1'eldipholle Email address D Demolition
5 gister d Floone Improvenent ontra or(IIIC)
HIC Registration Number J E.xpirationDate
III Cm pany met fflC e isrrant Name yG%yj� ® esL ec.,✓`.--
o,a d Strut y i ge Email address
City/Town,State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completad 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
[, as Owner of the subject property, hereby authorize r j t / )7J , lS�I1N�A—
to act on try behalf, in all matters relative to work authorizes,by this building permit application.
C�,.� �C' Z _ R-(-Y5-
I tint Owner's Name(Electronic Signa'MM) - Dnte
SECTION 7h: OWNEW OR AUTHORIZED AGEN'r 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 oFmy knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTI,S:
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 Ilontc Improvement Contractor(HIC) Program), will not have access to the arbitration
ro gram or uar:ttt fund under i .01. c. I42A. Other i,nportant information on the HIC Program can be found at
program g 4' b
\s%V\V,lllms Information on the Construction Supervisor License can be found at www.mass. o�:kIL
t. When substantial work is planned, provide the informatics below;
Total fluor area(sq. R.) _—(including garage, finished basement/attics, decks or porch)
(lross living area (ski. 11.) ---- --- Habitable room count.-- ---
Number or tireplaecs, _--------_--------_---- Number of bedrooms
Numbs ofbathroont, Number ofhtlt'ballu
I\pc nt h�umq ;y,lun Nunthar nt dicks/ poiihcs
Lnclo;ed Upon --
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