BPA 17-66 QEt7-!D
The Commonwealth of Massachusetts - - 4 10NAt Sr f
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
� This Section For Official Use Only
Building Permit Number: Date pplied:
{ Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal& On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Q! Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
B 'ef�escri tition of Proposed Work2: r < S
L: I�pkcA Ce_
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ $ i �(,�� ❑Paid in Full ❑Outstanding Balance Due:
Lf 3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-10 3*75 L4144 14OW
�� n � License Number Expiration Date
' Name of CSL Holder V List CSL Type(see below)
No.and Street t l Type Description
--rQAs�`e-0 / MLA-
o U Unrestricted(Buildings u to 35,000 cu.ft.
l 13 R Restricted 1&2 Family Dwellin
City/I�wn,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
x � � SF Solid Fuel Burning Appliances
CXl I Insulation
Telephone Email address D Demolition
5.2 Registered Home Im roveme t Contr� AJJ0 actpr(VIC)
CAA l CRcgistt4 —i
HIC Registration Nber Expiration
Date
HIwtpa 0a11 hr HI�CRegistrant Name v r A` t
No.and Strftei � i(IV� e171 Zb7 GO3 Email address
l�i7DSF- 1 l l J
C /Ti own,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.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 ..........9 No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR JJBUIL``DING PERMIT
I,as Owner of the subject property,hereby authorize�� ��
to 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 ins and penalties of perjury that all of the information
contained in this application is true d accurate e o y knowledge and understainding. /17++
rr� I/cl / 1 7
Print Owner's or Authorized Agent's Name(Ele tron' igna 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
www.mass. ov oca Information on the Construction Supervisor License can be found at www.mass�ov/dps/dps
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"