BPA-17-164 A The Commonwealth of Massachusetts 2011 MAR 13
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR SAI1-!ar 3Q11 ENI
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised j
One-or Two-Fam/Ijo Dwelling
This Section For Official Use Onl
Building Permit Number: Date plied:
Building Orficial([Tint Nnmc) Signature Date
l i SECTIO,2 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors i11ap & Parcel Numbers
l.1 a Is this an accepted street?yes no MtLp Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(fl)
1.5 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 Flood Zone Information: 1.8 Sewage Disposal System:
7-one: _ outside Flood Zone?Puhlic El Private❑ Check ifyes❑ Municipal G on site disposal system ❑
SECTION r: PROPERTI'01VNERSIIIP'
2.1 ON er'of Rec r 0
J J
Naaic Print) / City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF V110POSED WORK2(check all that appl-.
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of UnitsOther 0 Specify:
Brief Description of Proposed Work2: h A// n LIvU '
SECTION 4:ESTINIA`I'1 U CONSTRUCTION COSTS l
Item Estimated Costs: Official Use Only
(Labor and iviateriais)
1.Building $ U 1, Building permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ 3
O Total Project Cost (Item 6)x multiplier_.x
3.Plumbing $ 2. Other Fees: $
T
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression 'total All Fees;$
Check No, Check Amount: Cash Amount:
6.Total Project Cost: S 3 �d ❑Paid in Pull ❑Outstanding Balance Due:
I