BPA-17-182 –t:E l.E
The Commonweaith of Massachusetts �l� �� i �Cl�,'O� �
Board of Building Regulations and Standards Ii
Massachusetts State Building Code,780 CMR SAI GIVI
Revised iblar 3011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Taro-Family+Dwelling
This Section For OtTtcial Use Only
Building Perini tNumber: ateApplied:
3 /
-� Building Orficial(Print Name) Signature Date
1 1 SECTION 1:SITE INFORMATION
1.1 Property Address: f I r 1.2 Assessors il'lap & Parcel Numbers
l.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(ft)
1.5 Building Setbacks(ft)
Front Yard Slde Yards RearYard
Required Arovided Required Provided Required Provided
1.6 Nater Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public D Private❑ I Zone: r Outside Flood Zone? Municipal❑ On site disposal system ❑
checklfyesO
SECTION 2: PROPE11TV OIVNERSVIIP'
2.1 Ow r if Recor :t O l f 7 U
Name(Print) ity, tate,"LIP
.;'/ //d rid �f. ���E qK
No.and Street 'Telephone Email Address
SECTION 3: DESCRIPTi N OF PROPOSED WORK'-(check all that apply)
Nlew Construction❑ Existing Building Owner-Occupled fff Repairs(s) D Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Propose Wor 2: n ��// L t &1'A u iJ S knt.0
Sy• .cw di /vC� uf1 -- v U r c ata U
SECTION 4:ESTIIIIATPD CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) i
1.Building /'77 Z 1. 101—ng Permit Fee:$ Indicate ho,,-%-fee is determined:
❑Standard Clty/Town Application Fee
2.Electrical $ p Total project Costa(Item b)x multiplier x
3.Plumbing $ 2. Other Fees, $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire S Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
G.Total Project Cost: S %� ��f ❑Paid in Full ❑Outstanding Balance Due:
3 2
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 057
1_�J{-
OWE
t (0,066 License Number J Expiration Date
Name aC CSL Ifolder
is �1e, „1 Q List CSL Type(see below)
No.and Street Type Description
kl ayo 4 � �(� t � /1) tt Unrestricted(Buildingsa to 35,000 cu.ft.)
lIP A )VV R Restricted 1&2 Family Dwelling
Chyli otvn,State,ZIP M Mason
ry
RC Rool'ing Covering
WS I Window and Siding
lso� SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D I Demolition
5.2 Redstered Home Improvement Contractor(NIC) !C,[,r[j j
. 4c I ^G HTC Registration t�Number Expiration Date
HIC C an Name or WIC Registrant Name
t f
No. d Street
t 013 Email address
Cityrrown,State ZIP "Telephone,
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.In§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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of dte subject property,hereby authorize Am MA l f}i
to act on my behalf,in all matters relative to work authorized by this building permit application.
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Print Owner's Name(Electronic Signat m) Dake
SECTION 71b:OWNER'qJ(AVTHOJWED AGENT DECLARATION
By entering my name below,I hereby attest un r th pain and nasties of perjury that all of the information
contained in this application is true and accurat to t e be of y knowledge and understanding.
.�r�' / n ' 3 _ n '
Print Owner's or Audwriaed Agent's Name(Electronic Signature) V Date
NOTEM
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 PQ have access to the arbitration
program or guaranty fund under M.C.L.c. 142A.Other important information on the HIC Program can be found at
%.,ww.mass.go_v/oca Information on the Construction Supervisor License can be found at w%t,w.ma.cs.=vtdns
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 Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system plumber of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"'Total Project Cosy'