BPA 17-61 OUTSIDE RPRS rY
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 730 CMR
Revised Ahir 201
Building Permit Application To Construct, Repair, Renovate Or Demolish a JAN Zb
One-or Two-Fcnnily Dwelling 9
This Section For Oficial Use Onl
1
C. Building Permit Number: Date pplied:
J1311)
Building Official(Print Name). Signature Date
t` 1 SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Nlap&Parcel Numbers
�!� 'R A 1Le- 1 e3 5 i
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 t1) Frontage(It)
1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal eOn site disposal system ❑
Public 13"' Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP`
2. Owner'of Record:
._R ion ®�--- 5 Az ttn M A b t 1 O
Name(Print) City,State,ZIP
s HA2 r:-e:✓Y�.t� S"f
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction 13 Existing Building Owner-Occupied Repairs(s) Alterations) [3 Addition 13Demolition ❑ Accessory Bldg.13 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': W PA? F AGSA-) S U F.F--r-T,* CO2w E 2-
i3r�42 a5 Sz)i AzU MrNvM `!'
SECTION 4: ESTIbIATED CONSTRUCTION COSTS
Estimated Costs: Ofltcial Use Only
Item Labor and Materials)
Building S —t�*jp 1. Building Permit Fee:3 Indicate how fee is determined:
I.
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
1.Mcchmical (FIVAQ S List:
5.Mechanical (Fire "rota)All Fees:S
Su ression)
Check No. Check Amount; Cash Amount:
6.Total Project Cost: 5- "7 13Paid in Full 13Outstanding Balance Due:
l/3 I C-� 1ffT) F-o 9-
�,-_i 1 ti AA A,x t� -m C; r ocz�TSP
SECTION 5: CONS'T'RUCTION SERVICES
5.1 Construction Supervisor License(CSL) ,/ �S 0-)IS-3 0 12io—zy6
�� � � ,`y- License Number Expiration Date
Name of CSL Holder List CSL'rype(see below) V
2 0 r2-Z'x!f, Type Description
No.;uid Street
U Unrestricted JBuilding ug to 35,000 cu. ti.
q,.r 0f�tz 4. NA A D 1 -�k 3 R Restricted l&2 Fcunil Dtivellin
City/town,State,ZIP M Masonry
RC RootingCovens
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
FIIC Registration Number Expiration Date
FITC Company Name or FIIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.15Z.12SC(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 Istuance of the building permit.
Signed Affidavit Attached? Yes ..........0 No...........O
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN:-
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize �o M-AJ P/425�?N� -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Win..idY2,2 7 ��r�0-nC S / --26 -0-
Print Owner's Name( lectionic Signature) Date
SECTION 7b:OWNEW 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. ,r
�o AQ—,5.0 Q5 1 12-6 10
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(HIC)Program),will not have access to the arbitration
program or guaranty fund under N.G.L.c. 142A.Other important information on the HIC Program can be found at
www.m:u,.cov.'oca Information on the Construction Supervisor License can be found at www.mass.,,ov'.los
2. 1VI�en substantial work is planned,provide the information below:
'notal 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
'rype of heating system Number of decks/porches
'rype of cooling system Enclosed Open
3. "Total Project Square Footage"in#4be substituted t'or"Total Project Cost"
x a;