B-19-343 - 0027 ABBOTT STREET - Building Permit °° GK I ZZ
The Commonwealth of Massachusetts
Board of Building Regulations and Standards_ : EE
;, Massachusetts State Building Code, 780 CMR "M
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or DemcNIO APR -5 P t2- .3b
One-or Avo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
`�- -Building7 Official(Print e� Signature Date
SECTION 1:SITE INFORMATI N
1.1�P�r,1operty Address: �t 1.2 Assessors.Map&Parcel Numbers
`1.I a IsTis an accepted street?yes no Map Number—. --Parcel Number
4.3-Zoning-hrfor-mation: 1.4 Proper-tv-Dimensians: -
Z6ning-District Proposed Use Lot Area(sq ft) Frontage(11)
1:5-BuildmgSetbacks-(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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'__
2.1 wner'of Rec
Itooarda-— -la l r- r IH11A MIA D 1 Al D
Name(Print) - --- pity,State,ZIP -------
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction-❑- Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
- f Descriptioq of Proposed Work`:
t 0n
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) ( Total All Fees: S
1 Check No. Check Amount: Cash Amount:
6. Total Project Cost: S a,3S ❑Paid in Full ❑Outstanding Balance Due:
z
SECTION 5: CONSTRUCTION SERVICES
5. Construction S ervisor License(CSL) I
�..j�(_
U �i t�P
License Number Expiration bate
Name of CSL Holder
List CSL Type(see below) U
COOL
No.and Street Type Description
O I M R Unrestricted(Buildings u cu.ft.)
LI Y� rj Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
0 CileN.�► dV1T►R]t, dlRlQ, �9, I Insulation
Telephone Email address tyo t D Demolition
5.2 Registered Home Improvem nt Contracto HIC)
Dt� �dJ g HIC Registration Number Expiration Date
HIC pany Name HIC Regi nt Name
and Street , --- --Email address COS
—Gi /-T-ownt,State,—Z-IP - 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 .......... 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 U Sbh)�JNaS
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR 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-tliis"applicaf i true�ateo the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic ignature) Lfate
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.,ov/dps
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'
!•.tr
Revise Energy Planview Diagram,
Customer: Advisor Name: —
Address: Z�— ►� Any limitations to access by truck? Y
Town:
Site ID: C` 'Use the greater of the two BAS Irs when cakvWft for M"
#of stories 1 1.5 2 1 2.5 1 3 1 BA51: 15 cfm X#occupants X n-factor =
n-factor 19 16 1 15 14.4 13.71 BAS 2: .00W X area X height X n-fador =
Mechanical Ventilates Recommended:BAS>final CFMSO>(0.7 X BAS) Med+a*A Vent0dim Rimed:(0.7 X BAS)>final U M50
Is this par of a multi-unit workscope?Y r AIS WLOWSIrausatWn Cmes4 tt W Mx toosai x4Aff TnAs
VVQrkSCOPe:-__ ——_. —
Any work sm*oukside of best practices/approved by?
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