0014 TURNER STREET BPA 17-127 G K 2(o--7
The Commonwealth of Massachusetts rll !~�'t+_ .rte
OF
Board of Building Regulations and Standards CITY M
W Massachusetts State Building Code,780 C4N IALEM
FEBF�� 2� �, �jR��ed 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 Applied:
1
L
Building Official(Print Name) Signature 1ke
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I1-1 V cr,6 54+r-e-k
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
3Grr
Name(Print) City,State,ZIP
14 jVcre( 91-71 741-9L47 Li
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : Sr-�Wl c•�� <- %at- 4
e2,1-11
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:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
6. Total Project Cost: $D'GCheck No. Check Amount: Cash Amount:
J��jC) ❑Paid in Full ❑Outstanding Balance Due:
Vlts,% l.,-ro G-C . to - -7 i a - 0i-Ii 8
'1� MA ►t.E�:) 31 -�
SECTION 5: CONSTRUCTI SERV ES
5.1 Construction Supervisor License(CSL) —�,�'- ` /�
�� •G(�`� Y.cf fy License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
sck
No.and Street Type Description
Unrestricted(Buildings up to 35,000 cu.ft.)
Q`�5G
1yzw[J��r J` Restricted 1&2 Family Dwelling
City/Town,StaW ZIP M Masonry
RC Roofing Covering
WS Window and Siding
y� SF Solid Fuel Burning Appliances
r51 Ipv.�t. I Insulation
Telephone Email address GMoi:1.l't, D Demolition
5.2 Registered Home Improvement Contractor(HIC) i ores
V<VM 2AtNe-(S QZKSitVA-0t— HIC Registration Number Expiration Date
HIC om NameZr H C Registrant Name
No.and Street Email address
Iv-cw 4 PC A Q I C'Sd 1-r3T-7511
City/Town, e,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
I,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
contained in this application is true and accurate to the best of my knowledge and understanding.
WXW(51 1-u V;7//7
Print Owner's or Authorized A nt's Name(Electronic 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. og v/oca Information on the Construction Supervisor License can be found at www.mass. og v/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 halfibaths
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"