BPA-17-271 WINDOWS c Z� or
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The Commonwealth of Massachusetts
�j Board of Building Regulations and Standards' CITY OF
Massachusetts State Building Code,780 CMR 11 �Q 12 P I: EM
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: Date Appli
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Adf re 1.2 Assessors Map&Parcel Numbers
L l 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1r f Rld: 6-
gco
,* Cwc 2 a L,!!h a
14 -
Name(PriK City,S'FatF,ZIP
1TL�_SCh
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check al hat apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) eqAlteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Unitsther ❑ Specify:
Brief Description of Proposed WorkZ:
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 $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
M to L_6-1D Itj ya
SECTION 5: CONSTRUCTION SERVICES
5.1 Construc ' Sup 'sor License(CSL)
ci License Number x gra on Date
Name of CSL Hol4jr
UJ,5
t-7� List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/T�te-Zlp M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Ho e I ent Contr ctor(HIC)
HIC Reg trahon umber x d ation Date
HIC 2M N or a e
No. treet Email address
44 Lk\e
a4 L 13�zx"
Ci /Town,State,ZIP Tele one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be com eted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance the building permit.
Signed Affidavit Attached? Yes ..........010ar No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUIUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this build' g pe 't application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering m name below,I hereby attest under the pains and penalties of perjury that all of the information
contained' thi pli tion' true and accurate to the best of my knowledge and understanding.
Print O A orize Agent's Name(Electronic Signature) lAte
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.govroca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"maybe substituted for"Total Project Cost"