BP APP 17-69 .� The Commonwealth of ivlassachusetts
OF
Board of Building Regulations and Standards CITY SI
Revisedd,.Nur N
Massachusetts State Building Code, 780 CMR Vlar211
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Oficial Use Only
I Building Permit Number: Date Applied:
Building Official(Print Name). Signature Date
SECTION 1:SITE INFORMATION'
1.1 Property Address 1.2 Assessors Map&Parcel Numbers
.;1 eF/r.z�c wy
I.la Is this an accepted street?yes X no Map Number Parcel Number
1.3 'Zoning Information: / I.d Property Dimensions:
w�/ C y
"Luning District Proposed Use Lot Area(sq t1) 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP4
2.1 Owner'of Record:
Nme(Print). //// City,State,ZIP
_je/ �jz� ew %7v GJ7)'
No.mxl Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied J;(J Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
7-16
SECTION 4: ESTLNIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Buildin; 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
O Total Project Costs(item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4.Mcclianical (VIVA C) S List:
5.Mechanical (Fire
Su ression) total All Fees:S
Check No. Check Amount: Cash Amount:
G. Total Project Cost: S �!C CZI ❑Paid in Full 0 Outstanding Balance Due:
Se L3 (�30JZb1-I
'5670D TU �Z C HIT���/�4>�r��s�UlI'z 3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) n /r?,yf-��
JZ91Z 61/1w Z,�� License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
57
No.iind Street Type Description
,/J��✓��f, �/� C,/�� U Unrestricted(Buildings tip to 35,000 w.tt.
!/ R Restricted 1&2 Family Dwelling
Cityfrwn,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5�gistered home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIc-coni gy Name or FITC Rrgistrant Name '
No lid Street ' Email address
City/Tow State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 Is§uance of the building permit.
Signed Affidavit Attached? Yes ...... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN.:
OWNER'S AGENT OR CONTRA CTORAPPLIES`FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize �ZZ •/� _
t9 act on my behalf,in all matters relative to work authorized by this building p6mit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT 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 of my knowledge and understanding.
Print Owner's o cluthorized Agent's nine(Electronic Si ature) 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 Lig(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
xvwvv.ntass.gov:'oca Information on the Construction Supervisor License can be found at vyww.nlasS.gov'dns
2. When substantial work is planned,provide the information below:
'total tloor area(sq. R.) (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
fype of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Tota) Project Cost"