B-17-336 - 0044 VALLEY STREET - Building Permit I o 1� Ck 2 1
The Commonwealth of Massachusetts CITY OF
I' Board of Building Regulations and Standards
\!; Massachusetts State Building Code, 780 CMR Revised EM201!
to Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This.Section For Official:Use Only
1 Building PeinutNumber: Dat plied:
{ Building Official(Print Name) Signature : `r
1 SECTION is SITE-INFORMATION
1.1 Property Add - 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION.2: PROPERTY.OWNERSHIP':
2.1 Ow e 'off RecS, , r KL
Name(Print),.
City, at I
4a I
No.and Staat ele hoe Email Address
SECTION 3:DESCRIPTION OF PROPOSED.WORKZ(check that apply))
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number.of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS.:
Estimated Costs:
Item Official Use Only
(Labor and Materials)
1. Building $ "1. Building Permit Fee: $ Indicate how fee is detentiined
❑Standard City/Town Application-Fee
2.Electrical $ ❑Total Project Costa 1(Item 6);x rhultiplie I r x
3.Plumbing $ 2..Other Fees:I
J.
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression) Total All Fees:$ b.
Check No. Check Amount Cash Amount
6.Total Project Cost: $ 0 Paid in Full Or Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Lie Number Ex ati*Date—
Name of CSL Holder ` ,��,
1 List CSL Type(see below) lA6
l � TypeDescription,
No.and Street ype
1(/) U Unrestricted(Buildings up to 35,000 cu.ft.)
ZIP
J� R Restricted 1&2 Family Dwelling
City/I own,State,,Z ZIP M I Masonry
RC Roofing Covering
WS Window and Siding
rr ''� SF Solid Fuel Burning Appliances
�� 7 I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) — 1940,Y —
HIC Registration Number E pi lion Date
HIC Com Name or
AMstrant me
No.and S re t � Email address
City/Town,State,ZIP Telele hone��
SECTION 6:WORKEW 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 Issuanc 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 his uildin g permit application.
Print Owner's Name(Electronic Signature) Date
SECTION.7b:-OWNERt 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.
� .r4L;;,/)-7
Print Owner's or Authorized 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.yv/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 halfibaths
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"