2 DEWEY DRIVE B-15-359 ROOFING JACKET t cr, 19 q 2.t t I?taQ `,I-A. ETa,
The Commonwealth of Massachusetts Pzfzr n T
O Board of Building Regulations and Standards RECEIVED RCITY OF
Massachusetts State Building Code,780 CM SPECTIONA 7p`ev1cW20J!
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling S APR 30 A 4: 1 b
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This Section For Official Use Only
Building Permit Number: Date ed:
Building Official(Print Name) igaature Date
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SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
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1.1 a Is this an accepted street?yes ✓' no Map Number Parcel Number
13 Zoning Information: 1A Property Dimensions:
1 Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
l 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
ystemsPublic O Private O Zone: i Outside Flood Zone? Municipal O On site disposal system O
Check if yesO
SECTION 2: PROPERTY OWNER{SMPI
2rt of �C.• JQIf Mk--
112; '
SamCA 11 rd— pb-ods
(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(cbeck all that apply)
New Construction O Existing Building O Owner-Occupied Cl I Rcpairs(s) O Alteration(s) Addition O
-cl Demolition 137 Accessory Bldg D Number of Units I Other Cl Specify:
s Brief Description of Proposed Worlrz:
In-
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SECTION 4:ESTIMA'T'ED CONSTRUCTION COSTS
item Estimated Costs: Official Use Only
xft Labor and Materials
1.Building $1W,000 —' 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ O Standard Cityfrown Application Fee
CI Total Project Costa(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. $/t O. p Paid in Full O Outstanding Balance Due:
5-35
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SECTION 5: CONSTRUCTION SERVICES
5.1 ons on Superviso se(CSL) ^ C�'�' 1.7
la 1, Li ('cease Number Expiration Date
N e of CSL Holder
L -7 r�r nS 1e- A List CSL Type(see below)
No. �j Type Description
pr4JI(O—j— U Unrestricted uildia up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City State,ZIP M M
RC Roofing Covering
WS window and Sift
SF Solid Fuel Burning Appliances
li OZ� mheavq,34IN I Insulation
Tel one Email address • D Demolition
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5.2 ReogtereAHome Im ement Contractor(MC)
h &r IRC Registration N(umber Expiration Dfic
Effiff U&7 Company or C Re ' t Name
✓' c
No. SP!2142J PA /iJ-�/�— Email address
Ci /Town,State Tel hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GJ,t»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 permit
Signed Affidavit Attached? Yes..........0 No...........
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SECTION 7s: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 Wbaif,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electmnic Sigoaturc) Date
SECTION 7b:OWNERh 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 in application is true po accurate to the best of my knowledge and understanding.
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PrA er s or Authbrized Agind 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(HIC)Program),will nom{have access to the arbitration
program or guaranty fund under M.G.L.c.142A.Other important information on the MC Program can be found at
www.mass. ovg /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 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"
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