0001 SKERRY STREET COURT BPA-17-128E I V i
The Commonwealth of Massachusetts
O(1 i Board of Building Regulations and Standards CITY OF
lJ 0 Massachusetts State Building Code, 780 CNIR E e E 2 1QNBuildingPermitApplicationToConstruct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date.Applied::
Building Official(Pont Name). Signature Date
SECTION l:SITE INFORMATIOff
1.1 Property Address: ,1.2 flssessors Nlap&Parcel Numbers
5y eyyu )± oa r'
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Luning District Proposed Use Lot Area(sq 11)Frontage(R)
1.3 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 es0
SECTION 2: PROPERTY OWNERSHIP!`
2.1 . err
of Record:
M!3!3 Qr'97
Mme(Print) City,State,ZIP
I 1;k'dr'-J'14 )+ ')Ur+ ITi -7q(;r¢derrkScn(a Ue r ,t'ot
No.and Street I Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction Existing Building) Owner-Occupied )K Repairs(s) IN I Allen.tion(s) Addition
Demolition Accessory Bldg.13 Number of Units 7- Other Specify:
Brief Description of Proposed Work': eu
cj!zr: Zde
11 1r617L s
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Offlcial Use OnlyLaborandMaterials
1. Building S dd 1. Building Permit Fee:S Indicate how fee is determined:
2.ElectricalS 3d Qd
Standard Citylfown Application Fee
Total Project Cost(Item 6)x multiplier x
3. Plumbing S /Gr Osd 2. Other Fees: S
1.`Icchanical (HVAC) S List:
5.,\lechanical (Fire
Su ression) total All Fees:S
Check No.Check Amount: Cash Amount:
G.Total Project Cost: s2 /, -QQ Paid in Full Outstandin;Balance Due:
d
7 k P #Orz'e
NA i\ ,L.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CShcf /` ,' 2 20
License Number Expirat n trate
O 6 7—
N,une of CSL Holder List CSL'rype(see below) ed
2 L 0 0 0 r TYpe Description
No.and Street U Unrestricted(BUildings tip to 35,000 cu. fl.
Pe e,. /V Q Q Iv S` R Restricted 1&2 Famil Dwelling
cityrrwm,State, P ti Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7tA ?/7 3 3/ Q 6 G C 1/t ido, ' I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contra5tor(HIC) 3 Z !f2 S' Z7 so
C/KW4v rs
FITC Registration Number Expiration Date
111C Company Name or IHC Registrmt Name
LLocvsf
No.and Street
Email address
Ci /Town State ZIP ait
Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I c.15L$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..........1B No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEN.
OWNER'S AGENT OR CONTRACTOR AP/PLIE SLFOR BUILDING.PERMIT
1,as Owner of the subject property,hereby authorize K eb -er/
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 enter' my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain d i this applic ' n is a and accurate to the best of my knowledge and understanding.
oZ
Print t caner s or Aut rorize I gent ame(Electronic Signature) Date
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 ituf have access to the arbitration
proram or guaranty fund under ivi.G.L.c. I42A.Other important information on the HIC Program can be found at
www m:us.euw:'ocsr Information on the Construction Supervisor License can be found at w%-,w.mas-gov dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) including garage,finished basetnenttattics,decks or porch)
Gross living area(sq.11.) Habitable room count
Number of fireplaces Number of bedrooms
lumber of bathrooms Number of half/bathsTypeofheatingsystem
Number of decks/porches
rype of cooling system
Enclosed Open
3. "rural Project Square Footage"may be substituted for"Total Project Cost"