0000BAKERS ISLAND - PARC. #46-0080 SHED BPA-17-236 The Commonwealth of Massachusetts '
kBoard of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR ? ".
. 411
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling toil APA A 54
This Section For Official Use Only
Building Permit Number: Dam App
E<
�7 , ()(ficial(Print Name) Signature Date
•�--. SECTION 1:SITE INFORMATION
d1.1 Property Address: aml
Co 1.1 Assessors Map&Parcel Numbers
1.1,a Is this an accepted sheet?yes o t Map Number Parcel Number
1.3 Zoning Information: Ak 1.4 Property Dimensions:
Zoning District Proposed Use / b0 Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Y46 Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L a 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 y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition- ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work2: 5 ,c o' -ro
wreA+o t-VA awl jtz Rehr. .?tl 7r floor IQ"Q.C. VSL2%9 h•-.sy�s�_
T t fi ?1 ,9; �R/D� de&k .. .x G Cw J a-r a` o J V
SECTION :ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1.2ply 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ 133
Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $
List:
5.Mechanical"(Ire
Suppression)
$ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ - ❑Paid in Full ❑Outstanding Balance Due:
l �
SECTION 5: CONSTRUCTION SERVICES `0 E�
5.1 Construction Supervisor License(CSL)
^ ' cs �►
-� - koco►2y s �� - ate►$
Clk r-t O�-oF ku" H9.4i hlfj License Number Expiration Date
Name of CSL Holder
�8 List CSL Type(see below)
No.and Street Type Description
e,v Fid" 01 q 1,S U Unrestricted(Buildings up to 35,000 cu.ft
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7 9),-3 7<Q7 yy I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) =
0��'► HIC Registration Number Expiration Date
HIC Company Name or HIC Registrarit Name
lB Nec�.�'i�ar' Sf
No.and Street Email address
1S e..re -11 M A 01 q r S 9 7$ 37S 9Yy
Ci !Town,Stdte,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 of 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 Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con in in this application is t_lp and ccurate to the best of my knowledge and understanding.
P
P 'nt ;gr-'s or Xru-tFwAzed Agent's Name Elec onic 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 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/oca Information on the Construction Supervisor License can be found at www.mass.gov/das
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"