B-17-788 - 0017 ALBION STREET - Building Permit It CK
The Commonwealth of Massachusetts '{ g � FO1tl'
` g Board of Building Regulations and Standards
CIPALITY
I Massachusetts State Building Code,780 CMR 2�11 �� Zi
Building Permit Application To Construct,Repair,Renovate Or'Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
6 Buildmg Pe it Number Date Apph
�'tt91
Q
O�
1 Buildmg Official(Pent Name) Signature q Date
�sr
SECTION 1:SITE INFORMATION
Ll� �Property Address t 1.2 Assessors Map&Parcel Numbers
!n &'k"
1.1 a Is this an accepted street?yes� no Map Number Parcel Number '
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provid equired Provided Requiredr Provided
1.6 WaterSupply:(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 Owner'of Record:
rr 1ate, �O��,eSL �y f'l�d 0191 c
Name(Print) City,State,ZIV `
19 (Zezzl9 �� �7�8Sa`1�6� �ric�>-,�Ooc�,eS�c��,at�•�
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 El
Demolition 11( Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work: + gut New
5�-M4rock .Ploo►" hC
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
1.Building $ .0 6-n 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical ❑
$ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 71000 2. Other Fees: $
4.Mechanical (HVAC) $ D List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1 �� ❑Paid in Full ❑Outstanding Balance Due:
Cl��.i.e-0 $ �2 5 �, e
i
SECTION 5; CONSTRUCTION SERVICES
i
5.1 Construction Supervisor License(CSL) (�y S S 7 b o Z 3 7
Qil j A n O C�eS License Number Expiratioh Date
Name of CSL� Holder eZ2 2 List CSL Type(see below)
No.and Street Type Descnp ion
1 /tl Q /1)q 1 U Unrestricted(Buildings u to 35,000 cu.ft.
T' �/I I I R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
s RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
0 0 I Insulation
Telephone Email address D Demolition
5.2((Registered Home Improvement Contractor(HIC) I U 6 Q g 5 2 I
wr^6�1,n V- (a 5 HIC Registration Number txpiration Date
HIC Company Name or HIC Registrant Name
9—
No.and et x G cZ q b Email address
City/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 .......... Id 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 application41)
Er'lA r) 80(4 g -9
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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 this application is true and accurate to the best of my knowledge and understandi g.
C)lt,4 ,�
Print Owner's or Authorized Agent's Name(Electronic Signature) t 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. ovg /oca Information on the Construction Supervisor License can be found at www.mass.gov/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"
Saved Photo
p.
,
r
vt
� xF
r"_ r .. k
k p
16 $
t
r q ,
" 'Tp.
-i
d.
p
�F
L
1 . 3 �x o`
F w
"o;approval b an other
..,
Y Y
�t.'hav:$g�uri>s�iction.
as
Cat l LL
of A.,EM,MASS. - '�. °� j�'�,e>,� STa 1 R 5
Op BUREAU 0..
t z "-
PLA",'_'A?°APPROVED SOLELY FOR 1DElMhCATIWOF
IYPE AND LOCATION OF FIRE POTION DEVICEES.
Af L FIRE PROTECTION DEV!',cS _ f Ui3jEC. TO P
=1NAL TEST AND INSrECTION,FOR COMPLETE COT.7Pl'I
A'.
1111 will
Cfj
z
rt -" `rq
r
co In 3
�u IN
:%�'
lid-
v x ? any A
i
`3 /a
Y
x