8 INTERVALE RD - BPA-2009-671 The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7i'edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a l3boftmoku&
One-or Tiro- VYRD`i elling mom
Thisection For Qfrtilial Us Only
Building Permit Nuer: App!' d:
Signature: 0441.
y
Building Commissioner' nspec of Buildi Date
S I:SITE INFORMATION
1.1 ropert.�/y Address:
/� €f4 1.2 Assessors Map& Parcel Numbers
l fr°
I.I a Is this an accepted street'? Ma yes no P Number Parcel Number
1.3 Zoning information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq f) Frontage(R)
1.5 Building Setbacks(ft) j
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❑ Private❑ Check if es❑ Municipal❑ On site disposal system C3
SECTION 2: PROPERTY OWNERSHIP'
2.1 w r'of Record:
01 t/ V,,,/1 5,, i _y ;r'//NG,'
Name(Print) Address for Service;
178" -- ^
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Cl 1 Aheration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Prsed Work': _
f > '
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building 5 C) C7 I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical E ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: 5 s50 . 00 O Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) le5�12 20 /� Z
License Number Ex frau n Dale
Ngmc�of VCSl.(�„�(Hglder
�n(.. List CSL Type(sec below)
Addr•ss
Type Description
UI Unrestricted(up to 35,000 Cu. FI.)
Signature R Restricted 1&2 Family Dwelling
M klasonry Only
RC Residential Roofin Covering
Telephone
WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5. Registered ore Im rovement Contractor(HIC)
ympaVW
y Nam�ozr HIC Registrant Name Registration Number
Address 12- a
�Q/ �'y�/�/s'Sr Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... ❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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�:OWNERI OR AUTHORIZED AGENT DECLARATION
I. �✓.//��i7 /CC.•/�11 �� , 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
be /
%U ee15->-L/
Print ame 2,
cud w O
Signa ore of Owner or Authorized Agent Dale f
(Signed under the pains and penalties ofperjury)
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 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 110.116 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 healing system Number of decks/porches
Type of cooling system Enclosed Open
3. 'Total Project Square Footage'may be substituted for"Total Project Cost'