0001 QUEENSBERRY DRIVE BPA 17-174 The Commonwealth of Massachusetts y
Board of Building Regulations and Standard �''` ' FOR
Massachusetts State Building Code, 'h Ivll F)?TICIPALITY
� 780 CMR, 7 edition USE
Building Permit Application To Construct,Repair,RenovV#AMet tglisl a ANvised January
One-or Two-Family Dwelling 9
3 1,2008
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature: /4u,,,-v
Building Commissioner/Inspectol4f Buildings Date
_(1 SECTION 1:SITE INFORMATION
(�\�J 1.1 Property ress: 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yel no Map Number Parcel Number
1.3 Zoning Information: IA 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 yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' f Record-
;o--1
ak
Name(Print) ss for Service:
r" +,,it
Signature a ho
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ RepairsL[O] Specify:
eration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Oth
Brief Description of Proposed Work2:
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 $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
5
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
96 "N
License Number e
Name of CSL- Id
List CSL Type(see below) LIL
rd es Type Description
U Unrestricted u to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Si nature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registere om eme t Contractor(HIC)
HIC C pany Na e or HIC 'eg ran N e r g ssttratiion N mb r
4
jAd s
Expira i n e
�are Tkephotii� �-
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152.§ 25C(6))
Workers Compensation Insurance affidavit must be ompleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu a of the building permit.
Signed Affidavit Attached? Yes ..........16. No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 � ( 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1Wj,2K ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Prin me
Sigra re w er or uthorized Agent Da
Si ne under the pains and penalties of e u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I O.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"