B-17-599 - 0002 1/2 BECKET STREET - Building Permit The Commonwealth of Nfassachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 C1v1I411 JU4 29 A `ti'e�sed MaALEur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
1� This Section For Off
Use On1X
U, Building Permit Number:, Date Ap ..ted,
Building Official(Print Name) Signature Date,.
SECTION 1:SITE INFORNIATI01Y:
1.1 Prope+t Ad s: 1.2 Assessors Map& Parcel Numbers
t.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 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? Municipal❑ On site disposal system stem ❑
Public 13 Private❑ Check if yes❑ p p
SECTION 2:, PROPERTY OWNERSHIP ;
2.1 Own k :0 rO . I'K_L1� Sgien) Ck
Name(Print) City,State,ZIP 1 1
2 a�z P cut S�-, _ 7�%��I—�'��-z Mr-her 7C- r.-
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORK=•(check all that apply);
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other Ck Specify: Fr)C)
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS.-
Item Estimated Costs: Official Use Only..
Labor and Materials
l. Building I. Building Permit Indicdie how fee is determined:
❑:Standard.City/Totyn Application Fee•...
2. Electrical 5 s
❑Total.Project Cost..(Item.6)x multiplier. x
3. Plumbing 2. Other Fees: S
1. Mechanical (EIVAC) $ List:
5. Mechanical (Fire
I . ressiun) Total All Fees:,S
Check No. Check Amount: Cash AmOltllt:_
6. Total Project Colt: S ���� 0 Paid in lull 0 Outstanding Balance Duc:
l-
SECTION 5: CONS'rRUCTIOtN SERVICES
5.1 Construction Supervisor License(CSL) Joko [7 2-019
::�A' e _. a __ License Number Expiration Date
Name of CSL I[older
�� j L O�� �� �� List CSL Type(see below)
Type Description
No.and Street
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
6ityFTown,State,ZIP iV[ ivlasonr
Roofing Covering
WS Window and Siding
7O2 Z SF Insulation
Fuel Burning Appliances
`7 � � �, � [ Insulation
Telephone Em t address M D Demolition
5.2 Registered Home Improvement'Con tractor(I1IC) I
d'% / 7/
?PLe r! a;n II1C Registration Number Expiration Date
HIC Company Name or l-K Re stMmtVarne
��►► PMyyll
No.and S el El it address
fS Y"f 7022.
Ct /Town,State, ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152..§ 2SC(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 'plinn -
to act on my behalf, in all matters relative to work authorized by this building pe t application.
a'
.11211 b7__
r t weer s Name(Electronic Signature) Dat
SECTION 7h: 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 this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authurited:\;c ante(Electronic Signature) Date
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 Houle 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 MC Program can be found at
ww'W.ITlilS5.gu4'ii)Ca Information on the Construction Supervisor License can be found at mm-mass-gov`d
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 tirepluccs. -- — Number of bedrooms -- --_ -
Number of bathrooms _ Number of halbbaths
l'ype of heating systcnt _ Number ufdccks/porches
-------- --
I)pe of clolin;.,y;tcnt Enclosed _.. Open
3. "1 mal Project Foot;lge" Illay be substittacd for l")tA 111-oJect Cost"