B-17-340 - 0021 BOW STREET - Building Permit The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
EM
l Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
® One-or Two-Family Dwelling
This Section ForOfftcial'Use Only.
Building Permit Number: : DJZ
ate. plied
Building Official(Print Name) Signature _- Date'
SECTION--_- :SITE'`INFORMATION
1.1 Propertyedrft 1.2 Assessors Map&Parcel Numbers
1.1 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:,,PROPERTY OWNERSHIP'
2.1 Owne 1 .1V: A , �� A
�6 1 .Fes`
Name(Print) -- f T City,State,ZIP
C9l -L) Tj;7_ rnW6_0
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED'WORKZ(check all at apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units ❑ Specify:
Brief Description of Proposed Work 2:
SECTION4:ESTIMATEDCONSTRUCTION COSTS
Estimated Costs "
Item Labor and Materials Official Use'Only`
1.Building $ `— :1'. Building Peirntt Fee:,$ 7 Indicate how fee is determiiied.:'
2.Electrical $ ❑Standard City/Town'Application Fee
❑Total ProjectCost3(Item 6)x multiplier- x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (IIVAC $
5.Mechanical (Fire Su $
Total All Fees:
Sup
pression)
Check No Check Amount Cash Amount
6.Total Project Cost: $ _❑Paid in Full ❑Outstanding Balance Due
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SECTION 5: CONSTRUCTION%SERVICES
5.1 Construction 'c e(C L)
LiceAsirN&AEr Ex a '
Name of CSL Holder
List CSL Type(see below)
No.and Type Description
1 ►� f�,
1 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
� R?V I Insulation
Tee hone Email address D Demolition
5.2 Registered Home Improvement Co tractor(HIC)
HIC e is ation umber pi ion Date
HIC Q=a y am
4till I
yff .. I I )�
No.Xd Stre t Email address
City/Town,State,Zt YORplone,
SECTION 6:WORKERS'COMPENSATION INSURANCE AF.FTAYIT(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 Is ance of the building permit.
Signed Affidavit Attached? Ye ..-::......❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION.TO BE:COMPLETED,WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING;PERMIT
n
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this b ilding permit application.
Print Owner's Name(Electronic Signature) Date
SECTION,7b:OWNER1'OR AUTHORIZED-AGENT DECLARATION
By entering my name low,I hereby attest under the pains and penalties of perjury that all of the information
contained this a ca' is true and accurate to the best of my knowledge and understanding.
MJft"s-11Me—(Electronic Signature) a e
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.mgK. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/des
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"