B-17-1131 - 0009 VICTORY ROAD - Building Permit I
The Commonwealth of Massachusetts
Board of Building Regulations and Standards S CITY
OF
Massachusetts State Building Code,780 CMR
Z0 � z 1 Q :Red Mar 2011
Building Permit Application To Construct,Repair,Renovate r emolish a
n One-or Two-Family Dwelling
(�I 1 This Section For_Official Use Only,
Building Permit Number: Date"Applied
1
Building Official(Print Name) Signature Date"_
F
SECTION_1:.SITE INFORMATION
f� 1.1 Prope A dress: / 1.2 Assessors Map&Parcel Numbers
r pl
1.1a Is this an accepte treet?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 yesO
SECTION 2: PROPERTY OWNERSHIP' =.
F
2.1 Owner'of R ord:
R i(. k,A r 7 H o l 1np� nn cA✓1 Soy Le,✓vi I P I a . O/ 9 7 " �
Name('Prrint)1 City,State,ZIP
9 �/•C o� V [�173 B GNo a rare Lov►aCaSl,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF.PROPOSED WORK (check all"that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: _,rots y�
Brief Des ' tion of Proposed ork2: ,� e
>."SECTION 4 ESTIIVIATEDCONSTRUCTION COSTS '
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ L. Building Permit Fee $ Indicate how fee is`determind&
2.Electrical $
❑Standard Cty/Town Application Fee
❑•Total Project.Cost3{Item 6)x multiplier x"
3.Plumbing $ 2 Other Fees $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Su ression
Total All Fees.:$
Check No Check Amount Cash Amount
6.Total Project Cost: $ �, S, OO aid in-,Full„ ❑Outstanding,Balance Due:
E. GiVtL rJ tt,2t T-J,�
SECTION 5: 'CONSTRUCTION SERVICES;
5.1 Construction Supervisor License(CSL)
_021.1t r i 0 4 S M A License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)_
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 FamilyDwellin
City/Town State,ZIP M Masonry
Di9,1,27 RC Roofing Covering
WS Window and Siding
A o SF Solid Fuel Burning Appliances
O/-Y r7/ 6// �y,s-��o'�l/�'IS/��d� �+rQr� I Insulation
Telephone Email address G'o� D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company a or HIC Registryt Name //��
�,�s /' C/a or+o iota S/.� /8 /Go
No.and Street Email address
s.wA vs�o . of v o.7 9W L 7Y 76
Ci /To ,State,ZIP Telephone
}
SECTION 6:'WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L c;152
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...........0
SECTION 7a:OWNERAUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORU APPLIES FOR BILDING'PRIVIIT E -
I,as Owner of the subject property,hereby authorize &4 710111 S ri
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7ls 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
coVZd* this application isand acc rate to the best of my knowledge and understanding.
� // 2007
-PFinf Owner's or Au 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.aov/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"