B-17-463 - 0015 BECKFORD STREET - Building Permit I
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CITY OF
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Board of Building Regulations and Standards,. �.I i g$#EM
Massachusetts State Building Code,780 CM Revised Min 2011
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Building Permit Application To Construct,Repair,Renovate Or Mass a 5; 53
One-or Two-Family Dwelling
This Section For Official Use Only:
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Date Appl'
A" 1 Building Perintt Nutriber _ t
Building Offictal(Print Name) Signatue
SEC>ION 1; SITE INFORMATION ,
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Map Number Parcel Number
L I a Is this an accepted street?yes ✓ no
1.3 Zoning Information:Q'� 1.4 Property Dimensions: FA
Zoning District Proposed Use Lot Area(sq ft) Frontage(ff)a ,re
1.5 Building Setbacks(ft)
Side Yards Rear Yard
RequiredFront YardProvided 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�Zo 9 Municipal tQ tin site disposal system ❑
Public 0/ Private❑ Check if yesGd'
SECTION-2r.PROPERTVOWNERSHIP'
S k:
2.1 Owner'of Record: )Inc SGt l ern i r 019( fir I City,State,ZIP
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Name(Print)
Telephone a� Email Address
No and Street
77777777
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ ccessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: O CG
0 N 5 r
77
SECTION'.4 ESTIMATED CONSTRUCTION COSTS a
Estimated Costs: Offlcial Use;Only
Item Labor and Materials -
1 Biuldttig hermit Fee Indicate how fee rs detertYimed -
1.Building $ � V d
❑Standard,City/Town Apphcat{on"Fee
2.Electrical $ c�0 ❑,Total Project Costa(Item.6)x mulriplter x
3.Plumbing $ pup 2� Other=Fees $
4.Mechanical (HVAQ
5.Mechanical (Fire $ Total All Fees '
Su ression ;Check No"," Check"Arnount Cash Amount
6.Total Project Cost: $ �� ( ❑Patd to Full ❑;{Outstanding Balance Due
5I✓
�1
7777
SECTION 5 CON5TRU:CTION'SERVICES
� 5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
"Type Description k r
No.and Street
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
v\ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
—THIC Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town,State ZIP Telephone
777777777-7777777777,
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 I O BE COMPI ETED WHEN
OWNER'S AGENT OR:CONTRACTOR APPLIERY BUILDING PERNTIT ,
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.
Print Owner's Name(Electronic Signature)
Date
SECTION 7b OWNERt`ORAUTHURIZED 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.
LJs
Date
Print Owner's or Authorized Agents Name(Electronic Signature)
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 can be found at
www.iTiass.gov/oca v/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"