B-17-1168 - 0021 BUCHANAN ROAD - Building Permit The Commonwealth of Massachusetts.'; ' fad € 17,
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Board of Building Regulations and Standards '' CITY OF
Massachusetts State Building Code,780 Cl AvetuislA
MMar Revised Mar 2011
Do Building Permit Application To Construct,Repair,Renovate 1 : 3 4.
�Q One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied: ,
Building Official(Print Name) Signature Date. .
I SECTION 1:SITE INFORMATION
1.1� perly Address: . 1.2 Assessors Map&Parcel Numbers
u Qnbh
L l 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 Owner'of ecord:��
Name(Print) r J n I City,State,ZIP
e2 I BN cat un ati •a2G'9- 3�SZ
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alte ation(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify:
Brief Description of Proposed Work2:
73
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 360 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $
❑Standard City/Town Application Fee
s
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $'
4.Mechanical (HVAC) $ List: ,o�-L/L/
5.Mechanical (Fire Suppression)
$ Total All Fees: $
Check N6./34Dq Check Amount: Cash Amount:
6.Total Project Cost: $ 30Z� - � ❑paid in Full ❑Outstanding Balance Due:
(VIP1►L- �-b G.C. I7Z-AIZ
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7
' SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) g`-79�7 7 C1/1,
//
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) (A
No.and Street Eric W. Palm Type Description
3 Hilton St U Unrestricted(Buildings up to 35,000 cu.ft.)
1��♦ n�n'n R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP �9 M Masonry
RC Roofing Covering
WS Window and Siding
Gp SF Solid Fuel Burning Appliances
01 7�` 704! tf � I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /V/ .109111 3
1 Z�/�
Atlantic Westilerizadon HIC Registration Number Expiration Date
HIC Company Na o C e istra Name
1 ef�eson Avenue
No.and Street Sd1k1ngA 01970 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 f the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FORBUILDING PERMIT
1,as Owner of the subject property,hereby authorize F_r G 1 �1�✓t
to act on my behalf,in all matters relative to work authorized by this building permit application.
/h e
Print Owner' Name(Ele nic 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 a plication is true yd accurate to the best of my knowledge and understanding.
Print Owner's or Aut orized Agent's Name(Electronic Signature) Date
NOTES:
l. 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.gov/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"