BPA-17-269 C-1y, Lt z-n
The Commonwealth of Massachusetts : r
Board of Building Regulations and Standards ;,, �^ CITY OF
i ...r � �r��,. �t '`"�StAi�EM
Massachusetts State Building Code, 780 CMR .t
Re�vised Mar 2011
Building Permit Application To Construct, Repair,Renovate q��et�i
One-or Two-Family Dwelling
This Section For Official Use Only
C7 Building Permit Number: Date lied:
.� -44... V)/�l�
Building Official(Print Name) Signature Date
3
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record: 6X6 L 0 4A/'1 /7't.L/S ,0r4
Name(Print) City,State,ZIP
Y So U r(cJ.S-�,K S 619-28?-- Ski/
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(cbeck all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ft Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2:.R C MO ).- at4 denriiJ
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 $ E3 Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ L , Cin 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
6. Total Project Cost:
Check No. Check Amount: Cash Amount:
$
2 VUO' Lo ❑Paid in Full ❑Outstanding Balance Due:
h'�P, L\—C D 1A 14 w0 C, L
SECTION 5: CONSTRUCTION SERVICES
5.11 Construction Supervisor License(CSL) Q 7 21 q-5 o O
>q j kE&d J '� License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
-514F ----
l�o.and Street Type Description
�^ �ke- 4 U Unrestricted(Buildings u to 35,000 cu.ft.)
I�1 eA '`� � R Restricted 1&2 FamilyDwelling
City/Town State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�j>��(lh I. C i1iJS.�L✓ Solid Fuel Burning Appliances
' 9' C)'71 �'(9^-Y,.q q ti 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) , 9 M,3-31,9 9
GD `� 'j S `�^�S ���"3 C_ TfIC Registration Number Expiration Date
HIC Company riame or HICRegistrant Name
CH IgA.)e j�A Cc-
No.and Street Email address
-vim 7/
Ci /Town,State,ZIP -5pTelephone Co
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(KG.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..........leNo...........0
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 CoqpJ
to act on my behalf,in all matters relative to wor authorized bV this b ' permit application.
Print Owner's Name(EfeAronic Signature) Date
SECTION 7b: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 be f my knowledge and understanding.
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Print Owner's or Authorized Agent's Name(Electroni r ) 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
vvAvxv.mass. o_p, v/oca Information on the Construction Supervisor License can be found at x«vkv.mass.aov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
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