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3 LYNN STREET BPA 17-229 ADD MBATH The Commonwealth of MassachusettsT }}{ S Board of Building Regulations and Standards CItY OF Massachusetts State Building Code, 780 CMRS EM 1t11 MAR 31 vc r 2011 Building Permit Application To Construct,Repair,Renovate Or emoltsh a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date plied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers ( 3 X 1J(/ S V' AN, 1.1a 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 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 01 Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 6)1 L02 0 Name(Print) City,Stat6,ZIP J3 ZVAMJ No.and&reet Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied K Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: /9DDi iuC> & /Lnr IPI Flvc2 A0,1z &AL g, a /stw �ZFi �L'i7 LIJiT}/ /l,J/'sv IvvcjZ�2,a�L .4�v�/�l •lfS 57� • SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee:$L_Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ V O ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ p p 2. Other Fees: $ &21 �4.Mechanical (HVAC) $ U List: 5.Mechanical (Fire $ C) Total All Fees:$ Suppression) Cheek No. Cheek Amount: Cash Amount: 6.Total Project Cost: $ ;7,'y 0(.)U ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C /© , le License Number Exp atto ate Name of CSL Holder v _ List CSL'Type(see below) Ll Type- Description No.and Street U Unrestricted(Buildings Lip to 35,000 cu. It. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roolinit Covering WS Window andSidinst SF Solid Fuel Burning Appliances '�t7—OJl79�5��v1gUyTi� .t��i�ct' t/ 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date I IIC Company Name or HIC Registrant Name No.and Street Email address Ci /Town State ZIP Telephone SECTION 6:WORKERS'.COMPENSATION 11NSURANCE AFFIDAVIT(M.G..L c.152.4 25C(Q) . 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..........13 No...........O 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 - t9 act on my behalf,in all matters relative to work authorized by this building permit application. Tim j'►'lof2+N 3 -3 LA0,(7 Print Owner's Name(Electronic Signature) Date SECTION 71b: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 in this application is true and accurate to the best of my knowledge and understanding. :LOW- Ouraiirl -3131 2�0 Print Owner's or Authorized Agent's Name(Electronic Signature) D to NOTES: I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will uu have access to the arbitration program or guaranty fund under 1I.G.L.c. I42A.Other important information on the HIC Program can be found at www.niass.eov/oca Information on the Construction Supervisor License can be found at%v%vw.mass.-ov/dns . 2. When substantial work is plantic d,provide the information below: Total floor area(sq.ft.) N (including garage,finished basement/attics,decks or porch) Gross living area(sq.tt.) 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 1"or"Total Project Cost"