BPA-17-152 HOME RENOV. 0 , a'- 070,
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'the Commonwealth of Massachusetts
9
U31Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR Z��� k{ —8 Revised,blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
t One-or Ttvo-Family Dtvelling
This Section For Official Use Only
Building Permit Number: D e Applied'
4)
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION'
1.1 Property Address: 1.2 Assessors iNlap&Parcel Numbers
yG;'Lay%�:Q' 57411-
I.1 a Is this an accepted street?yes 'Sz no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
V FS00 'SCJ L+
"Zoning District Proposed Use Lot Area(sq t1) Frontage(It)
1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flo9d Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal�n site disposal system 13Publi9Private[3 _ Check if yes13
SECTION 2: PROPERTY OWNERSHIPe
2.1 Owner'of Record:
. 1t;,�Tl�.l -ir A.t�l�� '�1'��-!J'►—tAc� � �CJ�s-'�'��
time(Print) City,State,ZIP ,
_ Qc-x-
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ I Existing Buildin Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s))e I Addition ❑
Demolition )I I Accessory Bldg.❑ Number of Units Z 1 Other ❑ Specify:
Brief Description of Proposed Work': IJ€vim! W, Jho LL s't i
1�0
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
1. Buildin; $ '-1 b co
1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S i Cid ❑Total Project CosO((tem 6)x multiplier x
3. Plumbing S, .1 4!!:�)r C)C> O 2. Other Fees: S
List:
1.Mechanical (FIVAC) S t S'rp0.00
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6.Tutu) i'roject Cost: S 110 0-�Tb p Paid in Full ❑Outstandin;Balance Due:
,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) cs C)
J0
License Number Expi afflt. Date
Name of CSL Holder List CSL'rype(see below)
C9� lt_I.IP•��lb �Z'R - - Type Description -
No.and Street
R NQI�� ,� R Unrestricted Duildin s u to 35,000 cu. ft-)
R Restricted 1 n
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
or y M • SF Solid Fuel Burning Appliances
16N2TL,k/,W ky,-b 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State 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 Is§uance of the building permit.
Signed Affidavit Attached? Yes ..........0 No...........Or
SECTION 79:OWNER AUTHORIZATION.TO BE COMPLETED WHEN..
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[,as Owner of the subject property,hereby authorize ��•�� S � -
t9 act on :y behalf,in all matters relative to o tho ' ilding permit application.
cN 6Tb
Print Owner's Name(Electronic Sign 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 applicati n is ac of my knowledge and understanding.
Print Owner'sor orizc nt's NainJiElectronic 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 NLG.L.c. 142A.Other important information on the HIC Program can be found at
XVww.mass.Lov!oca Information on the Construction Supervisor License can be found at%v%�w.mass.gov'.los
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 CD Number of bedrooms
Number of bathrooms Number of half/baths 3
rype of heating system--LL "C X41 2- Number of decks/porches Z
rype ofcooling system Nm C— Enclosed Open •✓
.1. "Total Project Square Foota;e"may be substittited for"Total Project Cost"