BPA-17-263 RENOV. IN/OUTSIDE s
The Commonwealth of Massachusetts i 4
Board of Building Regulations and Standards ;i ION A(. S CITY OF
FM
r Massachusetts State Building Code,780 CMR
�?�� Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Ututy Affisg 2 A 8: 13
(� One-or Two-Family Dwelling
�y This Section For Official Use Only
� i
Nl Building Permit Number: Date ApAQd:
Building Official(Print Name) Signature V Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
��yy 17 c.(I�S/fig
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: # Q 1 P0
Name(Print— City,State,ZIP& Sr
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building a Owner-Occupied ❑ 1 Repairs(s) a I Alteration(s) Uri Addition ❑
Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2: ;rxj5r#tt w Ajwt 57 U 4 Roxicu4n. ci
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item � Official Use Only
Labor and Materials
1.Building $ ,o/U 1. Building Permit Fee:$, Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
0 (7 ❑Total Project Cost'(Item 6)x multiplierx,(
3.Plumbing $ 2. Other Fees: $ (J"'
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $-2 D D 0 13 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
0-70 Ct) License Number Expiration Date
Name of�CSL
/[folder � List CSL Type(see below)
NDescription .
No. ,�5 �jj vsp a CkIP—.
Unrestricted Buildin a to 33,000 cu. It.I I OA) Restricted 1&2 Family Dwelling
City/Town,State,ZIP ,Mt Masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
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 INSURANCE AFFIDAVIT(M.G,L.e.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 Is§uance of the building permit.
Signed Affidavit Attached? Yes ..........Ck No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED.WHEN:
OWNER'S AGENT OR CONTRACTOKAPPLIES 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.
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
o ined in thi applica' n i tt ate to the best of my knowledge and understanding.
L/ �� 2 d�
Print Owner's or Autho ed Agent's Name(Electronic Signature) Data
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 nut have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
xvww.mass.eov!oca Information on the Construction Supervisor License can be found at w++w.mass.gov'd�s
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (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 ofcooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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