B-15-356 ROOF s
CK 9 Z t l7lap 157A
The
The Commonwealth of Massachusetts pel-'m z}
O Board of Building Regulations and Standards RECEIVED�p C'OF
Massachusetts State Building Code,780 CMRINSpECTIONA 7t"e W,2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling 7815 APR 3 0 A 4= I b
l t This Section For Official Use Only
Building Permit Number: Date ed:
Lleou- q/G/
Building Official(Print Name) rgaature Date
4�
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Pared Numbers
V J 1.1 a Is this an accepted street?yes-!!!f: no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
-.� Front Yard Side Yards Rear Yard
i 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:
Publico Private❑ Zone: i outside Flood Zone? Municipal 0 On site disposal system ❑
Check if es0
SECTION 2: PROPERTY OWNERSHIP
2rt of C,• SpL� �
. e
Jame(Print) City,State,ZIP
I No.and Street Telephone Email Address
E SECTION 3:DESCRIPTION OF PROPOSED WORK'(cheep all that apply) If
New Construction O Existing Building❑ Owner-Occupied (3 1 Repairs(s) O 1 Alterations) Addition O
-1 Demolition ❑ Accessory Bldg.0 Number of Units Other O Specify:
C Brief Description of Proposed Work-2-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
u< Item Labor and aterials
1.Building ( ��, d MMa 1. Building Permit Fes:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost'(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: S
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $Suppression) Total All Fees:S
n Check No. Check Amount: Cash Amount:
j.kc 6.Total Project Cost: $/&0. DSD r 17 Paid in Full 0 Outstanding Balance Due.-
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SECTIONS: CONSTRUCTION SERVICES
5.1 ora on Snpervlao (CSL)
OS
la 1• Li ceasNumber Expiration Dau
N e of CSL Holder
�^ List CSL Type(see below)
No. /1--- , I �[ �f Type Description
U Unrestricted(Buildings to 35,000 cu.8.
R Restricted 1&2 Family Dweffing
CityState,Zip lyi i
RC Roofift covering
WS Window and Sift
SF Solid Fuel Burring Appliances
i OT� ON I L1511lation
Tel one Email address D Demolition
5.2 Registe Ho Insprerement Contractor(MC)
�1
n e, C..O re MC Registration Number Expiration Dfie
MCC ompanyor C Re ' t Name
tr' ,
No. S — f IV—3 Email address
Ci6rito State Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT OLG.L.c.152.4 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 petmi
Signed Affidavit Attached? Yes..........E3 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(Electrwk Signature) trate
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
i By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in application is trueye accurate to the best of my knowledge and understanding.
er s Jo Auth A t N 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 in the Home Improvement Contractor(HIC)Program),will nom{have access to the arbitration
program or guarenry fund under MG.L.c.142A.Other important information on the WC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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"