B-19-347 - 0033 BELLEAU ROAD - Building Permit The Commonwealth of Massachusetts
Board of Building Regulations and Standards ° FOR
� )('j �. SE ta.1vI,TNICIPALITY
Massachusetts State Building Code,780 CMS : USE
d ll�ar 2011
Building Permit Application To Construct,Repair,Renovat of a
One-or Two-Family Dwelling �'
This.Section For Official Use Only
1 Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: - 1.2-Assessors Map&Parcel Numbers
l.la 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)
t 1.5 Building Setbacks(ft) - 4
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 yes❑ Municipal❑ On site disposal system ❑
SECTION 2:.PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
?oil<l 0 2rI�?. ,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
r New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other �fy: 1c�Cr� J!(2
} Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials) Official Use Only
1.Building $ ZOO 1. Building Permit Fee:$ Indicate how fee is determined:
C ❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: _r.,
5.Mechanical (Fire $
Su cession Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ��L�� ❑Paid in Full ❑Outstanding Balance Due:
y
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ®('1
L License Number Expiration ate
Name of CSL Holder 'A
�, t ,r'. List CSL Type(see below)
No.and Street Type Description
IQ _ Unrestricted Buildin s u to 35 000 cu.ft.
1� Restricted l&2Fami1 Dwellin
City/Town,State,ZIP M Masonry
RC -Roofing Coveting
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition 5.2 Registered Hom(e�I�mprovement Contractor(HIC) -
trtlAp_
vTi1 �Lv f �_ HIC egistration Number 11(piriftic;6 Date
Hie Company Name or.1MC is t Name rr�r
No C �l ail address
Cloty/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 .......... [&,-' No...........13
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
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 this application is true and accurate to the best of my knowledge and understanding.
Pint Owner's or Authorized Agent's Name(Electronic Signature) qaY_�
i
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 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. opov/oca Information on the Construction Supervisor License can be found at www.mass. oQ v/dns
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"