0029 CHESTNUT STREET - BPA-16-40 RENOVATE MASTER BATH 5 qqq q4- f` l7
The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEIV O CITY OF
Massachusetts State Building Code, 780 CMR,,,P4SPECTIONAL SEMI
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a One- or Two-Family Dwelling 13 AD 21
This Section For Official Use Only
Building Permit Number: Dat Applied:
*te
Building Official(Print Name) Signature
9 SECTION 1: SITE INFORMATION
1.1 Property Address��: rr 1.2 Assessors Map&Parcel Numbers
'a. � e�
(1 1.1 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 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:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal stem ❑
Public❑ Private❑ Check if yes❑ p P system
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
t �Llgr/dQ�l d�9`G�✓'a,r�-e ✓mar�.� �� �/ q 7d
Name(Print) City,State,ZIP
A,? CA,��h
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s)JK Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : U
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 $ ,5' Oa-o ❑Total Project Costa (Item 6)x multiplier x
3.Plumbing $ �pD , 2. Other Fees: $
4. Mechanical (BVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount Cash Amount:
6.Total Project Cost: $ ��( a ❑Paid in Full ❑ Outstanding Balance Due:
2�} CIF�Srrv� r s-r �Zo
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
��l� � ago c3� �d
h --�= License Number Exp' lion ate
Name of CSL Holder -/
���CJ�JP � List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
S /i/4 Olq / R Restricted 1&2 FamilyDwelling
City/Town,We,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�6 _ / SF Solid Fuel Burning Appliances
611 q�- Y 6�QS � y(<C� 'I g (y'�y1p� I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC /� ^ [`� l0
f,-,14 W- C4,W PLA4 C7[/rn, -A HIC Reg��istmt7�on Number E pim'on Date
HIC Com any Name ovO IC gistran Name
0 ,zrs, /� /d (T�yKc 1
No.an treet ��0a r Tf,f/ ? Email address
City/Town,Sfate,ZIP < Tele hone
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 .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR"PLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize V((A,N A
to act on my behalf,in all matters relative to work authorized by this building p rmit application.
Print Owner's Natne(Electronic Signature) 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
com in in this application 's true d accurate to the best of my knowledge and understanding.
Jda- lz
Pr' wner's Aut orize ame(Electronic Signature) ate
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 can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.massgov/dps
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 Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
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