B-17-1072 - 0024 BRIGGS STREET - Building Permit (OqS 6c Cy—I(z-1�
The Commonwealth of Massachusettsti
'
Board of Building Regulations and Standa�f i ` , , 'FOR
- Massachusetts State Building Code,780 CMR MUNICIPALITY,USE z
Building Permit Application To Construct,Repair,Renovaa�r�mmol h llvUL Mar 2011
One-or Two-Family Dwelling
This Section For Official Use.Only
r $uildmg Petnit Number . : .Date Ap d: '
]Building Official(Pent Na* Signature Date
SECTION 1:SITE INFORMATION 1
1.1 Prygy A �ess: 5 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accept 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,9 Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal'On site disposal system ❑
SECTION 2- PROPERTY OWNERSHIP'
2.1 Ow erg of Record:
Name(Print) r City,State,ZIP
No.and Street Telephone• - Email Address
d. SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Bri f Description of Proposed Work': /NJ/ij/ h--9 AleA i c� S /-ate/�S/c�. /� ✓c...-s
AJ(NGw w ,Ccs..i' �x-..c� o/c w�i� New /f+�� f' h�►d �L .y�v+-.`ip� c..�+//�
r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials y
1.Building $ i r Dvd 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard CityfFown Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 22 ( 2. Other Fees: $ e
4.Mechanical (HVAC) $ 2 Y ovJ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 023�daa• uJ ❑Paid in Full ❑Outstanding Balance Due:
. �F tart/� �era-r.:►S
SECTION 5: CONSTRUCTION SERVICES {�
5.1 Construction Supervisor License(CSL) LS 08
Ida P 1'e,If ari tl License Number Expiration Date
Name of CSL Hold
List CSL Type(see below)
a� (alters
No.and Street T. . Description
1 U Unrestricted(Buildings up to 35,000,cu.ft.
PT ct bd li t, rho, 01 if G Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC RoofinR Covering
�g r / WS• Window and Siding
1776i—3 75^o 1p��l" SF Solid Fuel Burning Appliances
rC,7Crd R f&Yjt Cpn,eW� ��� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improv1ement Contractor(HIC) :Zskall
C A Ja lull- 11]n ,1 Iftt/d-�('I rw� �l C. HI Registration Number Ex tion Date
HIC Compan a or HIC Registrant Name
�l c� lry c-F sfic, a fxfi�rBGya�e�la Ce w,/-/
, cc.Kclam
No and Street NJ Email address
PcaboL, �rla D l QG O 9��37S ag61
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.1524§ 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
1,as Owner of the subject property,hereby authorize C-CA KIVIt IA fL 'l�k V
to act on my behalf,in all matters relative to work authorized by this building permit application.
.qy (�Yl9aS � L�-�- — GL�d W t
Print Owners a(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
contain i his a lication is true and accurate to the best of my knowledge and understanding.
!!V7�
Prin Owner's o A i d 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.ggv/oca Information on the Construction Supervisor License can be found at www.mass.eoy/dus
2. When substantial work is planned,provide the information below:
1 floor areas .ft. (including garage,finished basement/attics,decks or porch)
Total � g g g
( 9 )
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"