B-17-84 ROOFING -7 Z
The Commonwealth of Massachusetts
V,qA r, .,. FOR
Board of Building Regulations and Standards {, w r,s: .M .
WMassachusetts State Building Code, 780 CM kNi ALITY
Q J) �R USE
( Building Permit Application To Construct,Repair,Renovate Or 1��'t4 01A al �evi,c J Mar 2011
{�- One-or Two-Family Dwelling [
!� This Section For Official Use Only
! Building Permit Number: Date A ied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
L la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
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:
Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwnerl of Record,,
Name(Print) City,Siate,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:_
Brief Description of Proposed Worl2:
L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ � 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) $ List:
5.Mechanical (Fire $ —
Su ression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $"Lv��O' ❑Paid in Full ❑Outstanding Balance Due:
Z- � MAt t-- TD G L ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�� � �' � License umber Expiration ate
a e of CSL Holder
.- List CSL Type(see below)
No.and Street T e Description
U Unrestricted Buildin s up to 35,000 cu.8.)
`7� Restricted 1&2 FamilyDwelling
�it'y/Town,State,ZIP M Mason
ry
RC Roofing Coverin
WS Window and Sidin
p SF Solid Fuel Burning Appliances
% `p �� 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
J"1 1. A /",-2e 1 J HIC Registration Number Expiration Date
HIC Company Name or HIC Re strant ame
Mo.and Stre t f TIF
Email address
City/Town,State,ZIP Telephone
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 Issuance the building permit.
Signed Affidavit Attached? Yes .......... 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 Owner's Name(Electronic ignature) � Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,l hereby attest under the pains and penalties of perjury that all of the information
cort is
Ta-
11i17
is t 9d accurate to the best of my knowledge and understanding.
P int Owner's or Authorized Agent's Name(Electronic Signature) Date
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.gov/oc v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dr)s
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"