7 BRISTOL ST - BPA-16-1068 1141 c_K-
The Commonwealth of Massachusetts { l .
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct Repair,Renovate Or De�1liaE Q A 9 32
One-or T wo-Family Dwelling
Oo This Sc€tatar For Lkse
Building Perarh Niarrber Date App4k
�Q 'k8ng Oleigl tPri�Name) Sigaaiure �.> Ate
_ SFC7Ti 1:STIPlil ORMATTOIy"
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1.2 Assessors Map&Pareel Numbers
S�accepted street?yes no Map Number Parcel Number
nformation: 1.4 Property Dimensions:
Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(fl)
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.$Sewage Disposal System:
Public ClPrivate❑ Zone: Outside Flood Zone?
Check if Municipal E3 On site disposal system E3es
SECI'ION2: PR MTV ❑OWNERSH1P
2.1 Owner'of Record: n p
:a,2t�taa& CL1d
rd t�i%tPtssS rel � �a leA, , 04A o
Name(Print) City,Stats,ZIP
`7 1 S 6Q: WZql frnCcv3 Fl< e�dS@ o ,c�sT. et
No.and St[eM Telephone,., Email Address -
SECTION 3:DESCMPTfON OF PROPOSED WORKR(eheck all that apply)
New Consnuction❑ Existing$wilding❑ Owner-Occupied:l3' Repairs(s)r❑ Alterations) ❑ Addition ❑
Demolition ❑ Accessory$Idg.❑ Number of Units Other ❑ Specify: 1
$nefI7escriptionofProposedWork-2: l-� 1 (o a` ./
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n O
SECTION 4:ESTf1/ATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only .
(Labor and Materials
1.Building $ { CS 30 0! 2. Building Permil Peen$ ladicate koEv fee is determined.
O Standard Cityfrown Application Fee
2.Electrical $ 0 Taal Project Lasts(Item o x mutt lift x y
3.Plumbing $ 2. Other Fees
4.Mechanical (HVAC) $ 1ist:, j
5.Mechanical (Fire $
Su ression Total Ail Fees:$
r� Cheek No. Cheek Amours Cash Amount:
6.Total Project Cost: $ 2-1 O vv o Paid in Pull 0 outstanding Balance IArc:
SEM, 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �l 3I-z-1LreA7
Iii✓I O 7 License Number Expiration Date
Name of CSL Holder
q,, )) yI List CSL Type(see below)
u Vl tin y� 1 0 'Ft V 2..
No.and Street
� " Unrestricted uildm to 35 000 m.ft.
R I Restricted l&2 FamilyDwelsn
aty/rown,state,ZIP M I Masonry
RCI Roofing Covering•
WS Window and Siding
SF Solid Fuel Burning Appliances
-77q -d 3Z-6421.4 1 rnstdation
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
Ci PI'o State ZIP Tel one
size o N f:mrowm&S'GYT)►1YEl!ISATION VKURANCE AFFMD,,A RT(M.G.I.c.152.4 25CM
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...........O
STICTION 7a OWNER AUTHORIZATION TO HE COMPLETED WHEN
1YINER'S JNT R CO I HNC,
I,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.
Pridt Owner's Name(Electronic Signature) IDiate
SECTION 7b:OWNER!Oft AUTHORIZED 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 Owne ' d(A o ' d c irg'N' a ctronic 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.govtoca Information on the Construction Supervisor License can be found at www•.nrass.eov/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 beating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project CosP' '
l
For !S
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Nc�144