B-17-910 - 0009 BELLEVIEW AVENUE - Building Permit c,� l 3 3
� nq.wealth of Massachusetts
Board 6. uildmg'Regulations and Standards FOR
c J MUNICIPALITY
Massachusetts State Building Code,780 CMR USE
y
Building Pe0rinit�App�icati n To on tract,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use.Only
Buildmg Pemtrt Number Date 2-6!J- .
Building Official(Punt Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
_5 1�i21�2�iGa Av<.
Lla Is this an accepted street?yes no Map Number ' Parcel Number '
113 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
- k ,
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information:. 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal On site disposal system ❑
SECTION 2s PROPERTY OWNERSHIP' y
2qlo^ccoro
Owner'of Record:
I c
'Minn"nS Co a L- ,P'nA- ` ,( - ►�� !mod}oc�
Name(Print) City,State,ZIP
Loancle g �3b- bij� yanca,r� c Srna�'� aor►,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building I Owner-Occupied ❑ Repairs(s) Jg Alteration(s) ❑ Addition`❑
Demolition Accessory Bldg.❑ Number of Units_L Other ❑ Specify:
Brief Description of Proposed Work 2: -�k+ pnd tW clec,►W
at')k c k1n to, :n( Sys a k e l � aJ�h rti o w, R--•..��c 1a_ k{tom-•.
12�o C raolaca„y% 'A lcoarade -6 VNonrd �.0 Sivw kayo �1�A?.w+S
SECTION 4:ESTIMATED CONSTRUCTION COSTS `
Item Estimated Costs: Official Use Only'
Labor and Materials
1.Building $ 3� 0 p o 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 U p ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ D DO 2. Other Fees- $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.7I otal Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
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SECTIONS: CONSTRUCTION SERVICES - 1
5.1 Construction Supervisor License(CSL)
License Number /v Expiration Date a
Name of CSL Holder V
1(
c List CSL Type(see below) C-5
.Type Description .
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
y t SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) l7�g /0 / 5
HIC Registration Number Ex iration Date
HIC Company Name or HIC Registrant Name
No.and Street 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 .......... 0"— No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR.CONTRACTOR-APPLIES FOR BUILDING PERMIT
A,as Owner"of the subject property,hereby authorize
to act on in behalf,' m ers relative to work authorized by this building permit application.
wner'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.
flint Owner's or Author ed 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.Qov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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"
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