5 ABORN ST - BPA-13-110 INSULATION I'Ite C•ormronne;ddl or bLusachusctts
1 I y, , 11uard oI Ouilding Regulationsand Standards Cl1')' OF
I Massachusetts State Building Code, 7SO C NIR ti,\LI:,\I
Building Permit Application To Construct, Repair, Renovate Or Demolish a
rOne-ur riv,)4',a d Du vflh•%r
This Section Fur Otticiul Use Only
r1la
ing Permit Number. Date /pplied: _
lding;anacc;ep1td
rint Mena) Signature � D(c /
SECTION I: SITE INFORMATION
LI Assessors MAP SlPar el umbers
s this street?yes no Map Numher Parcel Nunnher
1.3 Zoning Information: 1.4 Property Dimensions.
Luning District Proposed Use Lot Area(sy 11) Frontage(It)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Reyuircd Pruvidcd Rcyuired Provided
1.6 Water Supply:(M.G.1.c. 40,§Ja) 1.7 Flood Zone Informations 1.8 Sewage Disposal System:
Ihiblie❑ Private O Zone: _ Outside Flood Zone? Municipal(3 On site disposals)stem ❑
Check if cs❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner)of Record:
Name(Print _ City.State,ZIP _
"/f/sa✓�/ S i f/-57JSo2
No.and Street relcphune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(ebeck all that apply)
New Construction❑ Existing Building❑ Owner•Oceupled ❑ 1 Repairs(s) ❑ Alteralion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specily:
Brief Description of Proposed Work': : / f I.-e- /-3-j
SECTION a: ESTIMATED CONSTRUCTION COSTS
lleml Estintaled Costs: Ofllclal Use Only
Il.ahur:md .\laterialsl
I. Building s I. Building Permit Fee: s Indicate how fee is determined:
' Llearical s ❑Standard Cily.Tusvn Application Fee
i
❑Total Project C ostt(lens 6)a multiplier —_--s
1. Plunihioq s '. Other Fees. S_
1. Nledi.ulical ill\ \('1 S List:
�u wcssiunt fora) .\n Fees: s
p, C'hcck No, ('heck Amount: Co. h �\nunum:
n Total 1'rojccl Cu.sl: ) w p Rdd in Full 0 UurstauJing Hal.mce Duo:
SFA PIONS: ('ONS7RUcrIONNF.RVl( F.S
5.1 ('unstructimt SSupen/iisssorr I.icetue(CSLI
�����".� U. f//.! /..�/� �- I flame Nunihcr ... _. I��pi etiaur}•jiie
N,intc o(L'SI. I hdJcr
j IuICSI. I)peVechelual__.-___ __ _
�f r
_
e_.---- -- W
Dcicripti..n i
No. .mJ Street
l I DudJR_' titcrin Sidin
solid Fuell)uming;\ppliunccy
�/ �" I huulwiun
etc hone Fomil oJdmmi D Demolition
5.2 Rel Istered Home Im )rovementtC,uIllractor(HHIIC) J
(_r�l/�J.S✓, I C Itegiau;lion Numlxa F%Piruliui Mg
III ompan Nance or I l C.14 gkirujaNjing
No. ui Sueet Entail adJress
"
Ci /Town. State ZIP Tole hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 25C(6))
Workers Compensation Insurance affidavit must be completed sS submitted with this application. Failure to provide
this affidavit will result in the denial orthe Issuance of th ' ng permit.
Signed Affidavit Attached? Yes .......... No...........O
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 %/// /l�lC Y
to act on my behalf,inall matters relative to work auth rized y Is bull IL�PPlication.
7,4
print Umier's Nutne(L•Iectrunic Signature) Date
SECTION 7b: OWNER O AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest u5.4pr the sins and penalties of perjury that all of the information
contained in this appli tion is true a d at the st of my knowledge and understanding. p�
n
wncr uthorircd,lgc sNnnwl cctrunic.�ignuuvo) Duty
NOTES:
Gvvner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
t registered in the Hume Improvement Contractor(HIC) Program),will nu have access to the arbitration
gram ur guarvuy fund under\1G.L. c. 1 J'.A. Other important information on the HIC Program can be lound at
tt ".n. + ,v t Information on the Construction Supervisor License can be found at t„+++ ni.n; •�:' ,q+
±, 11 hen substantial+wrk is planned, provide the inl'urmaliun below-
final 11uur area t sy. 11.1 , _.._I including garage, finished basnnenL auks,decks or porch)
Grusilisingareatsy. ILl __._ -_. -... , ._ flabiiableroomt oust
\untherol lircplaces _ _ \'uutherufhcdrwms ._ ... _. . _ . . .
\anther of hadtnvnis . . _ \umber ol'half hmh.s
11 pe of healing i)Stem \umber oI Jccks porches
' I\pcfaa.linysaci❑ I'nda,cd Open .
l ..l'oi,d ProlcCt Square Foma-l'e"min\ 1,e oh,mtjtvd 11❑ l'oi,il Projeet(o,f'