B-19-328 - 0001 ARBELLA STREET - Building Permit The Commonwealth of Massachuketts'��� j,�.Vt
_ CITY OF
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Board of Building Regulations and Standar .
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Massachusetts State Building Code,780 CMR�L� Revised Mar 2011
Building Permit Application To Construct,Repair,Re � dt�'Or'l�emisa
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: Q
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 ProXerty A ress:q 1.2 Assessors Map&Parcel Numbers
1.1a is this an accepted street?yes no Map Number Parcel Number
13 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 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 ye Municipal On site disposal system ❑
SECTION 2: PROPERTV OWNERSHIP'
2.1 r'of Jtgcord: VC, l��Q O
��//11 J'`
Name(Print) ��a City,State,ZIP ,
/I1L I�,J.�, ��I
!4.
No.and Street Telephone E nai ddress v
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) JZ( Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Uni Other ❑ pecify:
Brief Description of Proposed Work2: Gt vL 0i d `
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (LaborOfficial Use Only
and Materials nY.
�=- 1. Building Permit Fee:$ Indicate 116 fee is determined:
1.Building $ 10 p 00 ,
❑Standard City/Town Application Fee
2.Electrical $ L bG� .' ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2 vU�=— 2. Other Fees: $
4.Mechanical (HVAC) $ List: �_
5.Mechanical (Fire Suppression)
$ Total All Fees:$
a� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $.t oyp ❑,Paid in Full ❑Outstanding Balance Due:
t 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /, L�Dv 70
L�►Ae�'t� (;�f(� License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
N d Street Type Description
0 )o 1�+ U Unrestricted(Buildings u to 35,000 cu.ft.
0. , R Restricted 1&2 Family Dwelling
City/Town,State,VP M Masonry
RC Roofing Covering
WS Window and Siding
j/ SF Solid Fuel Burning Appliances
�� •s�`�.' I l�UC�Qttit�t0 b(iMI S�, I Insulation
Telephone Email ad(Tess D Demolition
5.2 egis ed ome Improvement Contractor(HIC)
1km al 110,131
E. 13 ZD
C egistration Number Expiration Date
I� C any e oF4)l�egistrant Name 1/'/�+/1�(� a&A CGI,S[`.
Njo�I d treet) Y /n l l SL4� 11(p E azl address
City/Town,State IP I (/' 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 .........,6� 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 authorizeQ 1 ►��'�� �, j�l�"�U�(�
to act on my behalf,in all matters relative to work authorized by this building permit application. �,
1&14/,/ - ] I
L�11
Print er's a(Electronic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By enter g inname elow,I hereby attest under the pains and penalties of perjury that all of the information
con in i a'on is true and accurate to the best of my knowledge and understanding.
Print 06er's or Au orized Agent'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.gov/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"