1 BENGAL LANE - BPA-15-1360 WINDOWS The Commonwealth of Massachusettsr F CITY OF
Board of Building Regulations and Standards RE. I` C
0 � Massachusetts State Building Code, 780CMIiiSPECT10tjA\L ER`LS it,
Rev e t it 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-FamilyDtveling 1015 DEC 10 2: ib
This Section ForOfricia1 Use On ' .
gBuildin Permit Ni:, Dat ppfled:
• jL.Ari' /off �')
-Building ORciel(Print Name) - - Slg�nalure•:'- ,. - - Date
SECTION 1•SITE INFORMATION.
I.) Property Address:!2 1.2 Assessors Map&Parcel Numbers
( Jl�r1 -
I.lo Is this an accepted street? no Mop Number Parcel Number
IJ Zoning Information: U t Q(�j, IA Property Dimensions:
Zoning District :.. Proposed Use LotAres(sgfl) Frontage(it) .
LS BuBding Setbacks(R)
- Front Yard S1Je Yamb` _ Rear Yard:
Required Provided -Required . .Provided Requited'' Provided
1.6 Nater Supply:(M.G.L d 40,§54) LTFIand Zone Information: 1.8 Sewage Disposgl Systems '
Zone: _ Outside Flood Zone?
Public O - Private O
Checkir eso
.Munidptil O On site disposal system O-.:.
SECTION 2: PRQPERTY0IYNER$HIPs
2.1 Ownerr of Record:
P-.Stell S+ Ilano'S
R�Wc(FnnI) Q 1 City,State.ZIP
1 Jtna21 L .. R�>�, 7dS 93t.
No.and Street J Telephone Email Address
SECTION(3:DESCRIPTION OF PROPOSED WORK'(check all that apply)`
New Construction O Existing Building 0 Owner-Occupied O .Repairs(s) O I Alterations) O Addition O
Demolition _ O I Accessory Bldg.13 Number of Units Other 0 Specify-
Brief Descript
pecify:BriefDescriptof Proposed Work':
n C 41I lF C� r, r W �L govt
u VC/'k r C—
SECTION 4:ESTIMATED COWSTAUCTION COSTS
hcm - Estimated Costs: - Official Use Only -
Labor and Materials
I. BuildingS 5 3 s' 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S 0 Standard Cityfrowo Application Fee
0 Total Project Costa(Item 6)x multiplier x
1. Plumbing S P 91herFees: S
a.Meehanical (HVAC) S List:
5.Nahanical (Fire $ Total All Fees:S
$U res., - -
p Check No. Check Amount: Cvh Amount
6.Total Prnjcct Cost: S _I $
S 0 Paid in Full 0 Outstanding Dal:mce Due:
Wra1-ntvU Tot Grupo t—T-P,
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) p q Q �qq
Z p bJ r License Number Expiration Dale-
Name of CSL[folder ll I List CSL Type(see below)
17 1.;1, .W ''10. I.Q.J i �, n Type, _ -: . Descrlplioa .
No.and Street -
U UnrestricleJ(Buildings up to35,000 cu. ft.
Vk e- R Restricted 1&2 Family Dwelling
City/Town,Stale,ZIP M Masom -
RC Rooling Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
q 1 I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) / Z 6 g/ 1-3
14D M•e, 6:$,00L HIC Registration Number Expiration Date
I IIC Company N,gme or HIC Registrant Name .
q Q {h 0 �fJr ✓1 ,d ICS
No.mid StreetEmail address
�t, rc�afs bof y /hV� ydl- Gf9- dq
Ci /Town State ZIP Tele hone
SECTION 6r WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G-L e.ISt§2$C(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 Isitianpe of the building permit
Signed Affidavit Attached? Yes......... No...........O
SECTION 76:OWNER AUTHORIZATION TO BE.COMPLETED.)VHEN?
OWNER'S AGENT OR CUNTRACTORAPPii FORBUILDING.PERMIT
1,as Owner of the subject property,hereby authorize ale&C
t9 act on my behalf,in all matters relative to work authorized by this building permit Wplicadon.
.S ,-- -e- C, a,%,+-CA, -I-' 12
Print Owner's Name(Elect is Signature) Dau
SECTION 7b:OWNERt ORAUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain n this application is true and accurate to the best of my knowledge and understanding.
of It 4/1 .a. tOn111- �"IA tc � �,L / 2
Print Owner's or Authorized Agent's Name(Electronic St ature) Date
NOTES:
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 W1 have access to the arbitration
program or guaranty fund under M.G.L.c.—142A-.Other jmportanl information on he HICYrogramcan be
to`undT
www.mass eov'oca Information on the Construction Supervisor License can be found at www.macs.��ov;dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) 'A (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
]. "Total Project Square Footage"may be substituted 1'or"Total Project Cost"