BPA-1-163 WINDOWS i
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The Commonwealth of Massachusetts A
" Board of Building Regulations and Standards CITY ,Q
Massachusetts State Building Code,780 CMR SALfar
!i'evlserl i1!ur- 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
® One-or•Two-Famlly Duelling
( This Section For Otlicial Use Only
(� Building PermUNtunber: Date k piicd:
Building Oriicial(Print Name) Sigmiture Date
SECTION 1:SITE I\'FO1L�IATTON
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
0� (./)(.t A.►� / "/{�/ll(_.
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 fl) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Slde Yards Rear Yard
Required Provided Required Provided Required Provided
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1.6!Yater Supply:(h4.G.l,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Puhlic El Private C] Zone:
Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY O11'NERSH IP'
2.1 OAF rt of Recor
o�: Pit`,�•�f Cru r /��1
Nantc(Print �— y,State,'LI
y 2, �/CA� Are ����L�E y -
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'-(check all that apply)
'New Construction❑ Existing Building Vi Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units I Other ❑ Specify:
Brief Description of Proposed 1Vor1-2: S' 1// yt
r<ticd vc.,t."
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and ivlaterials)
1.Building $ 1. Building Permit Fee:S Indicate hour 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: /CJ
5.Mechanical (Fire $
Suppression) Total All Fecs:$
Check No. Check Amount: Cash Amount.-
6.
mount:6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) OS7 T
MaAr Moam; License Number Upiration Date
Name oT CSL Holder
isUst CSL Type(see bclo%v)Newill 4 — L)
No.and Street Type Description
Ll Unrestricted(Buildings up to 35,000 cu.ft.)
tkk[Al A4& IMA 0060 R Restricted l&2 Family Dwelling
cie."frown.State.ZIP M Mason!j,
RC Roofing Covering
WS Window and Siding_
St, Solid Fuel Burning Appliances
lso� U14b I Insulation
Telephone Email address I D Demolition
51 Realstered Home Improvement Contractor(RIC) /6%61 t
vagc & MC Registration Number Expiration Date
i a . Name or 141C R ' t ant Nam
I '��nh A--t c!Tr,
NO.and Surd Email address
Ck4i� PA ('9w1wo 06-6
ty/Towri,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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........0 No...........0
SECTION?a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize kat P.Airl
to act on my behalf,in all matters relative to work authorized by this building permit application.
o(YA4 0^61 1112.(J-e0d
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 0,*AIMORIZED AGENT DECLARATION
By entering my name below,I hereby attest u qdcrthe at and alties of perjury that all of the Information
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contained in this application is true and accu e to t I ef knowledgea and understanding.
b of
3
A
Print Owner's or Audiori7xd Agent's Name(Electronic&(~) ' 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(NIC)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
%vwNv.mass,ggovLocaInf "Avormation on the Construction Supervisor License can be found at ,mass4ov d s
2. When substantial work is planned,provide the information Wow:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.it.) 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"may be substituted for'Total Project Cost" 77771