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0009 FILLMORE ROAD BPA-15-358 ROOFING -7 bo C 17(. Ery, The Commonwealth of Massachusetts P45?-m IT� O Board of Building Regulations and Standards EAG I Ep CITY OF Massachusetts State Building Code,780 CMRINSPECAL MW 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling 1115 APR 301A 4= I b t This Section For Official Use Only Building Permit Number: Date 'ed: L116W Building Official(Print Name) s7wature !Date ' 41 SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes_!!!!!:!_ no Map Number Parcel Number 1.3 Zoning Information: 1A Property Dimensions: Zoning District Proposed Use Lot Area(sq it) Frontage(R) 1.5 Budding Setbacks(fit) --- 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: Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' P2 rt of e-on tt� A)'J'6 - S'o�l�i•tT �1�. are(Print) City,State,W No.and Street Telephone Email AM= SECTION 3:DESCRIPTION OF PROPOSED WORW(cheek all that apply) New Construction O Existing Building❑ Owner-Oecupied ❑ 1 Re x&gs) ❑ Alteration($) Addition o 'd Demolition ❑ Accessory Bldg.❑ Number of Units Other O Specify: t Brief Description of Proposed WorV: iP-a � C SECTION 4:ESTIMATED CONSTRUCTION COSTS item Estimated andMCS s Official Use Only 1.Building S 1W,Di O 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total A11 Fees:$ Check No. Check Amount: Cash Amount: I©.ICC ra, 6.Total Project Cost: $l(v 0, aDa r ❑Paid in Full O Outstanding Balance Due: X, 3 Ca�tswpl_� �� t�- I ! D��O� 15 - 35r� sTi L-L w E �V 5_MJ�t.C=iora 15-35y '`�_fit Lt Kn 1s-35.8. _ t _ f SECTION'S: CONSTRUCTION SERVICES 5.1ons on Snpervleo se(CSL) OS 0-7TC i 7 ► l`j } License Number Expiration Date Na&e of CSL Holder � List CSL Type(sec below) Type Description No{{. U Unrestricted(Building to 35,000 cu.8. R Restricted 1&2 Family Dwelling City State,ZiP M masomy RC Roofing WS Window and Sift SF Solid Fuel Bunning Appliances Insulation Tei one Email addressi&JUI.MW D Demolition 5.2 ReglstertAflonv Imprortment Contractor(HIC) h L C40Pp H1C Registration N [umber Expiration Dift Iffiff Company`N C Rei t Name No.PhEmail address Ci6FftqjM State Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.¢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 permi Signed Affidavit Attached? Yes..........13 No........... 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 to act on my behalf,in all matters relative to work authorized by this building permit application Print Ownees Name(Electronic 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 inapplZ/ u ication is true accurate to the best of my knowledge and understanding. Ar 01 er s or Authkized Agintis 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 in the Home Improvement Contractor(JUQ 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or parch) 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"