BPA-17-74 ' 'the Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALENI
Massachusetts State Building Code, 780 CMR Revised,thir l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Oficial Use Onlyw
t Building Permit Number: Date p ie di '
Building Official(Print Name). Signature-V. Date
SECTION 1:SITE INFORINIATIO14
1.1 Property Address- 1.2 Assessors aNlap&Parcel Numbers
1.1 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 11) 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system [3Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owners of Record: RA
���L i✓ ,y(^,
tf�h e(Print) City,State,ZIP
1 Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction Cl Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alterntion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work--: L
w
G c LQ if y 4 12s
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlcial Use Only
Item Labor and Materials)
I Building S a 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S-
4..\lechmical
4..lechmical (FIv;1C) S List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
cc Check No. Check.\mount: Cash Amount:
6.Total Project Cost: S ' ❑Paid in Full 0 Outstandin;Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 0
Wo
� �Uc� v
License Number a on Date
Name of CSL Holder (/
,(� ► � List CSL'fype(see below)
�J a skiff Type Description
No.;u►d Street AU Unrestricted(Buildings tip to 35,000 cu. 11.
a
�✓ ✓►/ / R Restricted 1&2 FamilyDwelling
city own,State,ZIP M IMasonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Duming Appliances
I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
1A) IJfy J �� HIC Registratioh Number Expir tion ate
� mNam lilli -J� yAoe, qt N�+n71
N'►d Stree
it l sC�i 3 J Email address
A otgv
y
Ci own State ZIP Tele hone
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 Is§uance f the building permit.
Signed Affidavit Attached? Yes .......... 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 -
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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my a below, I hereby attest under the pains and penalties of perjury that all of the informati n
contait in tl ' plication i true and accurate to the best of my knowledge and understanding.
Print Uwnc 's or Authorized Agent's Name(Electronic Signature) D•to
NOTES:
I. 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.eovloca Information on the Construction Supervisor License can be found at ww►v.n►ass.sov'dns
2. When substantial work is planned,provide the information below:
"total floor area(sq. ft.) (including garage,finished basetnent/attics,decks or porch)
Gross living area(sq. 11.) 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. "'focal Project Square Footage"may be substituted for-rotal Project Cost"