TP APP 17-65 REMODEL K & B ~ *2_1 oct� t 2
The Commonwealth ofL*Vlassachusetts' t=r.
Board of Building Regulations and Standards SAY OF
Massachusetts State Buildin de,
g Co780 C 1IT JAN 21 A 13r6sed,Nur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
I One-or Two-Family D►velling
This Section For Official Use Onl
Building Permit Number: Date.Ap zeds
Building Official(Print Name) Sigtrature Date
pllt SECTION 1:SITE INFORMATION'
1.1 Pro er Address: 1.2 Assessors Map&Parcel Numbers
,71 � �GF..��FhJ eve
L l a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Luning District Proposed Use Lot Area(sq fl) Frontage(It)
1.5 Building Setbacks(ft) p o¢..-
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.4T§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal Mr000 n site disposal system C3Check if esL'l
SECTION 2: PROPERTY OWNERSHIP'-
2. tof R ogd:
�me(Print) 7 7 A ' 9 City,State,Z P
l rl=j J( K T 7 SK l J-7 °
No.and Street --�- Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) orl Alterations) Addition ❑
Demolition Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': t;7m'T/D1J TU R,—,E46,3 ;Tr55 APy3 P,55m
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Buildin; I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S a ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
q. Xlechanical (HVAC) S List:
5.\lechanical (Fire
Suppression) "Fula!All Fees:S
Check No. Check;lmount: Cash Amount:
6.Total Project Cost: �!� ❑Paid in Full 13 Outstandin;Balance Due:
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C�—LIV3O=A�f 3 , 3�,
',?O��L-7- -0/'7 0G(LL 6 License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
f F6 !"(e 27LF Srl-
No.and Street Type Description
L NN mR (J!rflJ.S U Unrestricted(Buildings up to 35,000 cu. 11.
/ R Restricted 1&2 Family Dwelling
Citylfown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SFSolid Fuel Burning Appliances
-7f fInsulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) 1615; 41
h�f�5�er- ( LUQ ASS `S HIC Registration Number E piruti n Date
I IIC Amd
Name or MC Registrant Name
��g� -g-- , C.yN�, MA-- t�� .�a�Uea zia »N e7
Nu.aEmail address
Ili/ ZSiCi3
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152.# 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 lshuance2fAe building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN..--
OWNER'S
HEN..OWNER'S AGENTOR CONTRACTOR APPLIESFOR 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 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 or Authorized Agent's 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(I-IIC)Program), will nut have access to the arbitration
program or guaranty fund under iv1.G.L.c. I42A.Other important information on the HIC Program can be found at
%aww.mass.1ctv'oca Information on the Construction Supervisor License can be found at ww%►•.n1us.1-Tov'dns
2. When substantial work is planned,provide the information below:
'focal floor 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
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
.1. "Total Project Square Footage"may be substituted for"Total Project Cost"