11 WITCHCRAFT RD - BPA The Commonwealth of Massachusetts 'RECEIVU
1 Board of Building Regulations and Standards `aAPE 11G4XyWV C .5
Massachusetts State Building Code,780 CMR Reviseed MqqdMi .-
20 1
Building Permit Application To Construct,Repair,Renovate Or Demolisloa- AY b A 3
One-or Two-Family Dwelling °
O This Section For Official Use Only
�n Building Permit Number. 'Date Applied: '
Butldmg-Official(Print Name) Signature Data
SECTION 1:SITE INP'ORmATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
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(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requved Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
/VSECTION2: PROPERTYOWNERSIIIEt
2.1 Owne
rt of c
Name(Print) qCi-tyy,State,ZIP
// `,11.77—# ". ZR- 7r 7--57
No.and Street Telephone Email Address
SECTION 3:DESCRIPT10N OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Wore:
SECTION 4.ESTIMATE!)CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ OOc) 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ / U 0,0 ❑Standard City/Town Application Fee
❑Total Project Cost?(Item 6)x multiplier x
3.Plumbing $ 2,900 - 2. Other Fees:
4.Mechanical (BVAC) $ List
5.Mechanical (Fire $ Total All Fees:$.
Suppression)
Check No: Check Amount: Cash Amount:
6.Total Project Cost: $ �� �� ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
'Construction Supervisor License(CSL)
w. (/vjhf'/2 License Number cation ate
Name'of CSV H'ld—
Idr" l List CSL Type(see below)
No.and Street (�'L� 5'2f" ;T Desaipflon..
h nrestricted(Buildings up to 35,000 cu.ft.
f� R I Restricted l&2 Family Dwelling
City/fowa,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
e y SF Solid Fuel Burning Appliances
—7�! Yv U/Gp/N o�/!Y�• I Insulation
Telephone Email address D Demolition
5.2 Re is red Home Improv en>>t Contractor(HIC)
7M /3trZG,/
_ A`i� k t• ti A HIC Registration Number xpim on Date
pan J�Registr�r t.Name ��v/G� '
No.and S �CQ C� �Email address
��2 � AY* a,�-az�d
i /Down,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 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 COMPLETEP WHEN
OWNER'S AGENT OR.CONTRACTOR APPLIES FOR UMI)MG PERMrr
I,as Owner of the subject property,hereby authorize 0174l,0'fa 9(, rLlti
to act on my behalf,in all matters relative to work authorized by this building permit application.
jai K/11/4 . /t / o
Print Owner's Name(Electronic Signature) Date
SECTION 7b OWNER' OR AUTHORIZED AGENT DECLARATION
By y name a ow, est under the pains and penalties of perjury that all of the information
contain in is applicatio and accu to t the best of my knowledge and understanding.
avta A.1_ lun S tro t�6
cViut Own is Name(Electronic Signature) Date
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 can be found at
»vw.mass.gov/oca Information on the Construction Supervisor License can be found at ww•w.mass.gov/dns
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'