BPA-17-267 � L4
The Commonwealth of Massachusetts
Board of Building Regulations and Standards SALETY M
Massachusetts State Building Code, 780 CMR
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling ^�
This Section For Official Use Only
Building Permit Number: Da ppled: zrR�
Building Official(Print Name) Signature D r
SECTION 1:SITE INFORMATION
1.1 Pr erty AdAress: 1.2 Assessors Map&Parcel Numbers (-n
1.1a 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' f Record:
Jut-1/2 1k t L L(J;o S/Itxtl5 - &4-t,4 0(0770
Name(P 'nt City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed
poed Work2: _ L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item � Official Use Only
Labor and Materials
1.Building $ ,,s 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard CityiTown Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
KgC2, Z
SECTION 5: CONSTRUCTION SERVICES i
5.1 Cot uction Supervisor License(CSL) cs—asqo
License Num6e-r' Expiry ion ateG
Name of CSL Flordef
��/'(� List CSL'rype(see below)
�.1 t t��\ `�� ' TYpe Description
No.cued Street
U Unrestricted(Buildingsa to 35,000 cu. 11.
S
61-7-) R Restricted 1&2 Family Dwelling
cityfr=eg,vail,ZIP Imasonry
RC Roolinst Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Itegistered Home Improvement Contractor(HIC)
L FIC Registrtflon Number Expire ion D:to
HIC o 1pany Name or HIC Regtrant Nam
No. Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.G.c.ISZ.¢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 Iskyance of the building permit.
Signed Affidavit Attached? Yes.......... No...........0
SECTION 7a.OWNER AUTHORIZATION TO BE COMPLETED.WHEN:'
OWNER'S AGENT OR CONTRACTOILAPPLIES.FOR BUILDING PERMIT
1,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
LSECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
enteringame below,I hereby attest under the pains and penalties of perjury that all of the information
p ' ation is true and accurate t e best of my knowledge and understanding.
thorized Agent's Name(Electronic Signature) D e
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 c1I.G.L.c. 142A.Other important information on the HIC Program can be found at
%v%vw.mass.gov:'oca Information on the Construction Supervisor License can be found at www.mass.gov-/dus .
c 2. When substantial work is planned,provide the information below:
"notal floor area(sq. ft.) N (including garage,finished basement/attics,decks or porch)
Gross livin,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. "notal Project Square Footage"may be substituted for"Total Project Cost"