B-17-408 - 0045 VALLEY STREET - Building Permit 1:4.7', f &T lUA tk,L.
The Commonwealth of Massachusetts �Q Y , ITY O P F� : Q r
Board of Building Regulations and Standards k ,.
Massachusetts State Building Code,780 CMR SALERevised Mar
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
t Building Permit Number. Date Ap i ef"'d:
1
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION ,
1.1 P o dres 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an aco6pted 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwp
1 'L 7
Name(Print) City,Sta e IP
Ca� f'
No.and Street elephone"
TEmail Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check ll 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':
4:-ESTIMATED CONSTRUCTION COSTS
SECTION
Item Estimated Costs: Official :Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ JDP7 Indicate how fee is determined:
2.Electrical $ / ❑Standard City/Town ApplicationFee
❑Total Project Costa(Item-6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC)
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No Check Amount Cash Amount
6.Total Project Cost: $ `
❑Paid in Full ❑Outstanding Balance Due:
IVlp�u3b SI t a �N may'• hby, c.��
SECTION 5: CONSTRUCTION SERVICES..
5.1 Construction S-uervisor/L'icense(CSL)
License Number Ex ra on Date
Name of CSL Holder
List CSL Type(see below) L{
No.and Street Type Description
�`� U Unrestricted(Buildings up to 35,000 cu.ft.)
&WJr-JZ
1—' - R Restricted 1&2 Famil DwellinCity/T6wdState M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registeree Home Improvement Contractor(HIC)
14& VVIle
HIC Registration Number E it n ate
HIC om n am C Registrant Name
No.and reipt
1WW � �r Email address
City/Town,State,Z � '1'
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 lssuance 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
�jyl
to act on my behalf,in all matters relative to work authorized by this buil mg permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERl OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
o tained in this application is true and accurate,to the best of my knowledge and understanding.
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
-,,Nww.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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 balf/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"