26 ABBOTT ST - BPA-08-854 SIDING The Commonwealth of Massachusetts
tt�r Board of Building Regulations and Standards FOR
�q MUNIU
Massachusetts State Building Code. 780 CMR. 7'h edition l,V.l'll'
W SE
Building Permit Application To Construct. Repair, Renovate Or Demolish a RewW.d Ainua ,
One-or Tivo-Family Duelling i tN)s
This-Section For Official Use Only
Ruilding Pei init Num r: �� Date Applied:
.� Signature:
Building ommissioned Insp}ct of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: ST 1.2 .assessors Map & Parcel Numbers
1.la Is this an accepted street'?yes_ no_ Map Number Parcel Number
l� 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage tit)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner o[Record l
ao Mo� _
/�I G
Name f Pnnt) Address for Servyen
Signature Telephone l/dam'-
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s)Al Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify n) N(�
Brief Description of Proposed Work
ri
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlcial Use Only
(Labor and Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost(Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Nance of f-'SL- Holder List CSL Type(see helow)
Type I
Description
Address U Unrestricted(up to 35.000 Cu. Ft,)
R Restricted I&2 Family Dwellin
Signature M Masonry Only
RC Residential Ruolin Coverin
Telephone WS Residential Window and Sidra
SF I Residential Solid Fuel Burning -% rliance huoall�uou
D Residential Demolition
5.2 Registered Home ImprovemenUContractor(HIC)
i I Registration Number
HIC C p• y Na or HIC Re isllrant Name
AJJre 0 Expiration Date
Signat I ' ` Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.S 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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGgNT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 hY+ol r 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: OWNER' OR AUTHORIZED AGENT DECLARATION
1 J� n f 4 " I ) ,as Owner or Authorized Agent hereby declare
that the statements Ind information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
IA A-
Prinl Name I 3 ' ��
Signature of Owner o ut Date
(Sign d under the pains penalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contructur
(not registered in the Home Improvement Contractor(HIC) Program), will M 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 110.116 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"