BPA B-15-353 ROOF CK- ,7 9 q Z:$, 17too (1?(O°Ery,
The Commonwealth of Massachusetts Pt57-m
0 Board of Building Regulations and Standards RECEIVED E�F DCITY OF
Massachusetts State Building Code,780 CMRINSPECTIONA ]p`evJs 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family nwel ing 1115 APR 30 1 A 4� 1 b
I This Section For Official Use Only
`►j Building Permit Number: Date 'ed:
L'I'ow
y t'
Building Official(Print Name) Signature ! Dow
SECTION l:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
r
1.1 a Is this an accepted street?yes_!!!!!: no Map Number Parcel Number
1.3 Zoning Information: 1,4 Property Dimensions:
1 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
-� Front Yard Side Yards Rear Yard
l Required Provided Requirod Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private 0 Zone: , Outside Flood Zone? Municipal O On site disposal system ❑
Check if yes13
SECTION 2: PROPERTY OWNERSBW
2rr of RC'
e e
same(Print) City,State,Zip
I No.and Street Telephone Entail Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction O Existing Building❑ Owner-Occnpied Cl I Repairs(s) ❑ 1 Alteration(s) Addition O
t1 Demolition ❑ Accessory Bldg.❑ Number of Units I Other O Specify,
S Brief Description of Proposed World:
Ir C
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs. Official Use Only
Labor and Materials
1.Building $1W,000 1• Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) S List:
5.Mechanical (Fire $Sson Total All Fees:S
si
n Check No. Check Amount: Cash Amount:
6.Total Project Cost: s 1t7�. D�U r ❑Paid in Full ❑Outstanding Balance Due:
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✓ D�-�o�. �s^ 359
E _L, 15- 3 60
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SECTIONS: CONSTRUCTION SERVICES
S. uniton Superviso Be(CSL) s 7 17A�
ZjymLige Number Expiration late
N of CSL Holder
�� ��� �S)� � List CSL Type(sec below)
No. �`[ Type Description
U Umealricted(Buildings to 35,000 cu.f i
R Restricted 1&2 Family Dwelling
Cary State,ZAP M M
RC Roofing Covering-
WS window and Siding
SF Solid Fuel Burning Appliances
Ii O� ON I tnanlation
Tel one Eresil J101.
XAM D Demolition
i
5.2 RegloterrA Home Imprqvement Contractor(HIC)11 J
h L CO r HIC Registration Number Expiration Dite
Companyor C Rc ' t Name
►�' c
No.ROWS ,
�y�_�Q Email address
CiState Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c—15L g 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 issuance of the building pomni
Signed Affidavit Attached? Yes..........0 No...........
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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 pains and penalties of perjury that all of the information
contained m' application is true accurate to the best of any knowledge and understanding.
).
Aaq. ,or—A 71
t N (E is 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 m the Home Improvement Contractor(HIC)Program),will M 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.nuss.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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 Nw nber of bedrooms
Number of bathrooms Number of hall7baths
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"