B-19-240 - 0008 BRITTANIA CIRCLE - Building Permit ~ SL4 q CK 2-32-I 1
The Commonwealth of Massachusetts -�
* Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR Revised Mar 2011
® "ilding Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
(� This Section For Official Use Only
Building Permit Number: Date Applied:
v Building Official(Print Name) Signature Date
_ 771
SECTION 1:SITE INFORMATION
1.1 roperty Address- le, 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 wner'of a ord:
L u -i �A � Yl(,d4 D Iq
Name Print) City,State,ZIP
x t5M .VI 10-CI' YC4.L -g�5 i 9 i'r�-s- Cap cony S+
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)'`�1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: %
Brief Description of Proposed Work': '
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:
2.Electrical $ ❑Standard City/Town Application Fee 7L
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
3 T 6.Total Project Cost: $ Check No. Check Amount: Cash Amount:
(� ❑Paid in Full 0 Outstanding Balance Due:
M P\
r SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�J t� n � (� � License Number Expiration Date
Name of CSL Holder � ]
L� C�� List CSL Type(see below) V
No.and Street Type Description
�O /J I I /�� j /i Q U Unrestricted(Buildings u to 35,000 cu.ft.)
City/Town,State,ZIP/ vim' i (J (1 R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning.Appliances
o� J'�"il� ��p_r l��®(1`�e%}(J ! •�( I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor C)
�io ins Dl --- E&APcim HIC
C Registration Number Expiration Elate
HIC o pa Na or HIC istrant D(r_ame
char y[�
N� �SJtreeu rn ,n, n � , ^� 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 .......... 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
to act on my behalf,in all matters relative to work authorized by this building p&6it application.
^U�Gt o r mil-
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.
,_J_A A T t-QA- U-80t - 162 3 - 7--1 �'
Print Owner's or Authorized AgenU Name(Electrons ignature) 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 informarion on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.goy/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"