B-17-735 - 0003 BOSTON STREET - Building Permit The Commonwealth of Massachusetts 41 F . OF
Board of Building Regulations and.Standards
SA
Massachusetts State Building Code,780 CMNI j AUG _8 LEM
l i SAMar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A ied:
e Vie L
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
S 60_A1g, 5�
1.1a 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:
Public Private❑ Zone: _ Outside Flood.Zone? Municipal On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Oww�'of Record:
1;��c-2T �Cn,�lz.��r✓1 d tiT 1-94 2 S/ "ZU 3
Name rint) City,State,ZIP
—?954—Co3ZZ iC� NIJ R D 4 u7•a2em 6A.,7-e PZOIJ,
No,and Street Telephone Email Address NLT
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : p an e)a d f'N 5-" r iC
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.:Electrical $ /� ❑Total Project Costa(Item 6)x.tnultiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ �� Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 5� ❑.Paid in.Full ❑Outstanding Balance Due:
Y 1 ( O T`n r�"t,
SECTION 5: CONSTRUCTION SERVICES l
5.1. Construction Supervisor License(CSL)
License Number Expiration Date
1NT'ame of CSI.Holder
List CSL Type(see below)
No.and Streetk Type Description
Unrestricted(Buildings up to 35,000 cu.ft.
J R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
" , �N,2i d geim (.,. o M I Insulation
Telephone mail address D Demolition
5.2 Registered Home.improvement Contractor(HIC) /6 5-32 Z ( r
P t A PAd)a (017 f C'fi dml FIIC Registration Number Expiration Date
HIC Com any N e or HIC Registrant Name r , / ,
No.and Street Ern—ail address
D t,e J rA o 19 ZJ 7Pr—9r3 Sao 9
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 .......... 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 Jefffta tl Q 1 G +&A` GtI
to act on my behalf,in all matters relative to work authorized by this/building pe it application.
Print Owner's Name(Electronic Signature) Da e
SECTION 7b:OWNERI 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.
kz /` `� kb-7/o
Print Owner's or Authorized Agent's Name(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 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.p-ov/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"maybe substituted for"Total Project Cost"
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