12 ABBOTT ST - BPA-09-529 2 PELLET STOVES The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
k� Massachusetts State Building Code, 780 CMR, 7"edition
Building Dept
t� Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tiro-Fan ' • welling
tion For Offici I Use Only
Building Permit Number: VPat5 Akplied: •2 • O
Signature: , 2�, pal
Building Commission r/Ins cctor of Bu s Date
1: SITE INFORMATION
X 1.1 Q,roper�ty�.A dresq; S� 1.2 Assessors Map& Parcel Numbers
Tope
bb a �7
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 R) Frontage(ft)
1.5 Building Setbacks(it)
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 a 'of R�cor
X n 1-, ouc) rune
Name( irni Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupie Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other X Specify:
Brief Description of Proposed Work': _
//YS/,g/ 2 /�gLLIF7 SToV�S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ Standard Ciry/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) otal All Fees: $
Check No. Check Amount: Cash Amount:_
6. Total Project Cost: $ aid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
1, License Number Expiration Date
Ngmc of CSL-Helder List CSL Type(see below)
T Description
Address U Unrestricted u to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Mason Onl
RC Residential Rooting Coverin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name
Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 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
1 , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW ORAUTHORIZED AGENT,DECLARATION
I ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si ned under the andenalties of
NOTES:
i. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"