22 BELLEAU RD - BPA-1-874 SHED The Commonwealth of Massachusetts
CITY
Board fly Board of Building Regulations and Standards S t' y
Massachusetts State Building Code,780 CMR Revd' d Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a "`�jb AUG. S
One-or Two-Family Dwelling A O S+
Ibis Bastion Fpr f),�c3al•Use
Bu#ft P*im -;AFtaatier Date Applied:
13m"Idwg eial(Pri�Nama) Sigaatrae
1l SECTION 1:SM HVP'(1 Ii1T,pU1�7..
1.1 Pra dd�� 1.2 Assessors Ma &Parcel Numbers P
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zgnmg 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 al stem O
Public❑ Private❑ — Check ifyesO P disposal sy
SECTION 2: )*ROPERTYOWNERSN#Pt
errotRecrq d:
ane t) qty, t y., � d9�"Qt` =33 G'd+7 •,�G
22 &deod - ' ] r
No.and Street elephone EnuilAdotess -
SECTION 3:DESCRIPTION OF PROPOSED WORKS(obeck all that apply)
New Constmction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other O Specify:
Brief Description of Proposed Worle:
/ ^ K
x
SECTION 4:ESTWATED CONSTRUCTION COSTS
Item Estimated Costs: Oflicial Use Only
(Labor and Materials
1.Building $ 1 Building Permit Pee:$ Indicate how fee is determined;
C Standard Cityfrown Application Fee
2.Electrical $ O Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ �✓��
4.Mechanical (HVAC) $ '
5.Mechanical (Fire $ Tout All Fees:$
Suppres$ion
t32eok No. Cheek Among: Cash Amount:
6.Total Project Cost: $ 00 O Paid in Fall ❑Outstanding Balance Due: ..
SECTION 5: COINS7'RUCTTOA SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
,Name of CSL Holder
List CSL Type(see below)
Type Description
No.and Street
U Unrestricted(Buildings to 35 000 cu.&
R Restricted 1&2F Dwell=
City/Town,State,ZIP M Masonry
RC Roofm Covering
WS Window and Sidina
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
CiV,/ wn State ZIP Tel hone
SECTMN 4:WO tIMRS'COMPENSATION 9 URANCE A"MAVIT tAL.GJ-e.152.3 25C(0)
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
SEC3'LOIN Tai OWAR AUT116RIZATION TO HE Copol ETEA WREN
OWN$WS NT 4?;C9 FO HNG PIUUWU
1,as Owner of the subject property,hereby authorize
to ab[on t bah ,in all ma rs rel to_work authorized this building permit application.
` Print 0whaes Ns1i3*1rFVCtrh tire slDate
SEC 4DN 76:OWNER'OR AUTHORU"AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date -
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 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
w�vw.mass. o>; v,�oca Information on the Construction Supervisor License can be found at www.nuass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemenUattics,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 beating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'