B-17-602 - 0072 VALLEY STREET - Building Permit c �
A
' The Commonwealth of Massachusetts 5 'C o '
Board of Building Regulations and Standards
j Massachusetts State Building Code,780 CMR SALE 20
Building Permit Application To Construct,Repair,Renovate Or Demolish4 g
One-or Two-Family Dwelling
' This Section For Q#ficial Use Only, rti;
1 Buildmg Permit NuiYiber D e Appled r
1
Budding Official(Picot Nam')'; Signature
SECTION l' SITI±;INFORMATIQN 4 ,
1.1 PropertyAd r ss- ' 1.2 Assessors Map&Parcel Numbers
1.1a 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: PROPERTX O"ERSHIPi
2.1 Ow ri of eelord: ,t^ �,l/ � '
IxName(Print) City,State,ZIP J" I V V
72- Vc, 6j7-w/p-%$'7 �uve15 (9.gati06,C ,4-u
No.and Street Telephone Email AddressT
SECTION 3:DESCRIP.TION OF PROPOSEDWORKZ(check all thaf,apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: 10 X I'L
SECTION 4:ESTIMATED GONSTRVCTION COSTS . '
Estimated Costs:
Item Offic►al Use Only
Labor and Materials
1.Building $ G S°� 1 Building Permit Fee $ Indicate how fee is determmecl
lj Standard City/Town Application Fee
2.Electrical $
p Total Protect Costa(Item b)x nuitiplier x.
3.Plumbing $ 2 Other'Fees.
4.Mechanical (HVAC) $ Ltst ` C1.
5.Mechanical (Fire $Suppression) Total All Fees.
$�
Check No. the Amount: Cash Amount:
6.Total Project Cost: $ 0 p Paid in Full ❑Outstanding Balance Due
Gt,c�,e 1. 7 -:7
,y
SECTION 5: CONSTRUCTION SERVICES
5.I Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder list CSL Type(see below)
Type, Description ..
No.and Street
U Unrestricted(Buildings u#to 35,000 w. It.
R Restricted 1&2 Runily Dwelling
Cityfrown,State,ZIP bl Masonry
RC Rooling Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M:G,I;:.c.15Z.§2$C(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..........0 No...........O
SECTION Tat OWNER AUTHORIZATION TO BE.COMPLETED.WHEN)
OWNEWS AGENT Oil CONTRACTOR APPLIES:FOR-BUILDINd.PERMil
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 71b:OWNEW 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 i his application isArue and accurate to the best of my knowledge and understanding.
\ / Date
Pain caner s or Authorized Agent's Name(Electronic Signature)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor, (FIIC)Program);will nuf have access to the arbitration
program or guaranty fund under 1M.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
%vw%v.mass.►rov,•'oca Information on the Construction Supervisor License can be.found at%vw►v.mass.�ov/dns .
2. When substantial work is planned,provide the information below:
"Total fluor area(sq. tl.) (including garage,finished basementlattics,decks or porch)
1. Habitable room count
Gross living area(sq.t )
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"