67 APPLETON ST - BPA-2008-883 INSTALL 2 WINDOWS The Commonwealth of Massachusetts
Town of
Board of Building Regulations and Standards ' "
t Massachusetts State Building Code, 780 CMR, 7`"edition >
Building Dept
{P Building Permit Application To Construct. Repair, Renovate Or Demolish a
One-or Tiro-Family Divelling
This Section For Official Use Only
Building Permit N ber: Date Applied:
Signature: "` ^+1v 0
Building Commissioner/Inspector of Buildings Pate
SECTION 1:SITE INFORMATION
1.1 Propert Addrjels: ,� �nl 1.2 Assessors Map& Parcel Numbers
L I a Is this an acce�p^te�(d�(;streelJ�7 yes_ no Map Number Parcel Number
63 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ti) Frontage(R)
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?
Public 13 Private 13Zone:
if es❑ Municipal C3 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerlof
ct
Name(Print) � k Address�+for Ser
"`
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all!Jhat apply)
New Construction❑ I Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work°:
fY1tP r7
i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard CiryfTown Application Fee
2. Electrical 5 ❑Total Project Costa(item 6)x multiplier x
3. Plumbing 5 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: S
q�Q r Check No. Check Amount: Cash Amount:
6. Total Project Cast: E f J Ja �.. 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES !
5.1 Licensed Construction SuperNisor(CSL) `T
Limnsc umber E.apua 0D
N,;pne of CSL- H der List CSL Type(sec below)
ddr s T, Descri tion
U Unrestricted(up to 15,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
ig ture
M Masonry Only
RC Rcsidential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered How proI V110 v m n C or(8 ) I JAy 3
HIC Compart r tiler IC RegistantN Registration Number
2W 5
ress , tel)0
pEzpiratio--ddd Dap
ture elephone 4
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6))
Wo ers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1• eG nTiFi'(.1 -, as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
Zonle ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. 1
n mie-
Pri N e
gnatur o Owner or Authorized Agent Da[
if THuned rider the pains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and I I0.R5. respectively.
2. When substantial work is planned,provide the information below:
Total foots 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'may be substituted for"Total Project Cost'