36 BOARDMAN ST - BPA-15-1247 ROOF The Commonwealth of Massach,It,I,�ry E(CTIOMAL SE�tVit S
a Board of Building Regulations and JTadraS 9ALEOf
Massachusetts State Building Cade, 780 CNIR
�QIS N(�V I0 pis � kevised:t'Im201/
Building Permit Application To Construct, Repair, Re vate r Demolh a
y One- or Two-Family Family Ihvelling
This Section For Official Use Only
Building Permit Number: Date pplied:
A�5
Building Offciat(Print Name) .Signature - Date
SECTION 1: SITE INFORMATION
��apl�sE
rAddress: 1.2 AssessorsMap& Parcel Numbers
ccepted street?yes no Map Number Parcel Number
F13ZoningInformation: L4 Property Dimensions:
ng District Proposed Use Lot Area(sq ft) Frontage(ft)
. Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (NI.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal❑ On site disposal system ❑
2tOwner'of Record: SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record:
n �aRir�-'R C I,-e in.,-a nl 5-ct I ev,, 014— 0 t 9-7 0
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Constmetion ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. El I Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': 1n 5- -c l( 5 ckar-P ✓bO r.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building $ t f Lt-7 I. Building Permit Fee: $ Indicate how fee is determined:
�. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cos['([tem 6)x multiplier x
3. Plumbing $ 2. Other Fees: $.
4. Mechanical (HVAC) $ List:
Ze
5. Ntechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: '4-1 8 ❑ Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
r0 SLicense Number Expiration Date
Name of of CSL—
NO/ 5 t List CSL Type(see below) vl
No. and Street t Type Description
iln „L c� .� U Unrestricted(Buildings u m ——101
City/Town,n, SI e,ZIP P,l rI Restricted 1&2 Family Dwelling
Nt Nlasonry
RC Roofing Coverin
WS Window and Sidine
G r� SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ,D( �D C? /_
^}' •' �2r�.it co- S� /K C- ' - HIC Registration Number Expir cation Date
HIC Compan�Name or H[C Registrant Name
N O ✓�h
Nond Street Email address
�a Com, f} O I ck` l O
Ci /Town, State,ZIP Telephone
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 .......... IR No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize l /,�y i S ZO✓2
to act on my behalf, in all matters relative to work authorized by this building per it application.
�-,, (o +,,,,-4 d' c,- NOV 10 2015
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
Bye ring my name below, I hereby attest under the pains and penalties of perjury that all of the information
I, ' d this a I cation is true and accurate to the best of my knowledge and understanding.
r� NOV 10 2015
Print Owner's or Authorized gent's Name(Electronic Signature) Date
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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"may be substituted for"Total Project Cost'