BPA 17-18 REROOF -7-7
Che Commonwealth of Massachusetts
Board of Building Regulations and Standards �1� JAN _9 CITY
Massachusetts State Building Code, 780 CMR Rev e,, .1, 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family D►velling
This Section For Official Useonly - '
Building Permit Number. Date.Appl' at
Building Official(Print Name). Sipature We
SECTION 1:SITE`INFORIVIATION.'
I.1 Property Address: 1.2 Assessors Nlap&Parcel Numbers
I.I a Is this an accepted street9 yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Luning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP,
2.1 Owners of Recor : `
ir+✓ *q Vcu 6 S A Lo n-, /",4 O 4 O
t�ne(Print) City,State,ZIP
IIx C1 -7 k? -7 4 k 3 + 72-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR10(check all that apply)
New Construction❑ Existing Buildivner-Occupi epairs( Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg,❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': "r- t '4)cAgwG L.Q s.
` � nps,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ a �p a& I. Building Permit Fee: Indicate how fee is determined:
O Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost((tem 6)x multiplier x
-3.Plumbing $ P Qther Fees: S
4.`icchinical (I-IVAC) S List:
S.Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
G. 'falai Project Cost: S t �O ❑Paid in Full 13 Outstanding.Balance Due:
Vyl41 l-tip TO (.G I/I 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construc.tion6upervisor License(CSL)
D0,6 to c1; License Number Expiration Date
Name of CSL holder
List CSL Type(see below)
No.and Strew Type. ' Description .
'RaQbey 0 4 d 1 R`b U Unrestricted(Buildingsu to 35,000 cu.ft.
rR Restricted 1&2 Family Dwelling
City/Town.State,ZIP M masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
'7 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 O 81 t"
�✓ �` �G�"T� FIIC Registration Number Expiration Date
111 Company Name or HIC Registrant Name
street53 t g ,1 Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFRDAVIT(M.G,L.c.15; 2SC(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 Isi uance of the building permit.
Signed Affidavit Attached? Yes..........a No...........O
SECTION 7a:OWNER ARITHOItITATIOX TO BE COMPLETED.WHEN..!..:','
OWNER'S AGENT OR CONTRACTORAPPLIES FOIL BUILDING PERMIT
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:OWNER'OR AUTHORIZED AG@&fLT-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 bdst of my knowledge and understanding.
Print Owner's or Authorize tint's an Electronic Signature) Date
NOTES:
1, An Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor
(not registered in the Home Improvewent Contractor(HIC)Program),will uu have access to the arbitration
program or guaranty find under&I.G.L.c. 142A.Other important information on the HIC Program can be found at
%vww.mmss.gov'out Infww
ormation on the Construction Supervisor License can be found at �� .masAlL�
s.�ov .
2. When substantial work is planned,provide the information below:
'total floor area(sq.ft.) (including garage,finished basemendattics,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"