14 ABORN ST - BPA-13-92 ROOF /�� - ---- I'lie C'onm»unwealdl of ibt;usachusclts
is hoard of Building Regulations and Standards Cl IN OF
si. ",l;ts.aachuselts Statc Building Codc. 780 C NIR SAlli.\I
Building Permit Application TO C-onsiruct, Repair. Renovate Or Demolish a
one-or rtt•r,-k1unill•Dwellin.q
This Section For 011iciul Use 0n1
Building Permit Number:
Building 011kial(Print Mane) Bute
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Slap di urtel Numbers
7
I.la Is this an acce led street? 'es no Map Nutnher Parcel Nju,,Nr
1.3 Zoning Information: 1.4 Property Dimensions:
Lining District Pn,poscd(Jw: Lot Area Isq 11) I•rontuge 00
1.5 Building Setbacks(R)
Fruit Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40,154) 1.7 Flood Zane Information: 1.8 Sewage Disposal System:
Ihtblic❑ Private Cl Zone — Outside Flood Lune?
Check ifa0 Municipsd❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
sox /�/�t/ 4d,4ZI OR70
Nwne(print) City.State,ZIP
I`>` Afsers/ S' Y( C32J�d
WO-1 nd Streetrelephune bmail Addmss
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Cl Owner-Occupied ❑ Repairs(e, ❑ I Alterallon(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number f Units_ Other Iq Specily:
Brief Description of Proposed Work':
a �
SECTION J: ESTIMATED CONSTRUCTION COSTS
(tent Estimated Costs:
I labor and.Materials) Ofllclal Use Only
I. Building S I. Building permit Fee: S Indicate how let is determined:
2. FIccirical S ❑Standard City'Tuen Application Fee
I ). I'lumhinq S ❑Total Project C'oslt(hens 6)x multiplier
_. Other Fees: S
J. \Icch.m ical ill\ \(•) S List:
S \Icch.mical (Fire /K� _ -- -- — -- --- . . .
i \u, fCSS 10ne S 0 faf:el .\II
b I'mal Project CUvt: S Check No. _...__('heck:\mtiunC __._Ca,h \m,nun:
❑P.iid in Full 0 Oulsrmding H.Il.utce Duc:
sr,('I'ION 5! ('ON.S FRUCTION SFK%'I( F";
1.1 1 ion Julien isor License iik St.)
i Npir.awn IMIC
I cene Ntiml,cr
L St.
PC Inscription
No. and street
It Itctricted Id:21-111,11) Decllin
Sl , asoll
L iINfr...n, .wic 'RC R,11111 coscrin
window.uld Sidi"
SF Solid Fuel 1111ming tippliances
I 111sulation
DemolitionI(nwilAdirv.sA
5,2 Registered Ilome Improvement;A,ull,icior(1111C)
licghtrallun Number I %,11ruill"UJIV
HIC01,11pall) Nanwor sistrunt Name
Entail address
No. and Street
Ci ITown.state ZIP relc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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.
yes ..........C3 No...........E3
Signed Affidavit Attached? -1
ZA I
SECTION AWN 7a-. OWNER AUTHORIZATION TO BE COMPLETiDwHEN
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.
Z/1
to
Print oeI%er'sNwna(Elect nieSignaturo)
— SECTION'7b:OWN E IF51%AUTHORIZED AGENT DECLARATION
By entering my name below.I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of rny knowledge and understanding.
Dutu
print
.NOTES.
tt to do his her o%vn work,urin owner who hires an unregistered contractor
unregistered
I
I. An Owner%%hu obtain$a building perm have access to the arbitration
actor(HIC) Progranill.will LOU n I access Program
1. d at
inut registered in the Home Improvement Cuntr a �have rant can be round at
gograill or guaranty fund under M.G.L. c, 14,.4.other important information on the HIC Prog
r
I can be round at �io\
I Information on the Construction Supervisor License
the information below: 's J.,
2, litrit substantial\wfK Is PI-11.... provide i including garage. finished basement attics,decks or porch)
rota) (lour area I,+ Habitable rown count
(Irt)ij li\iogareatici. It Number kit'hedroomi
bathroollis \'umhcrofJccks. liordics
I Fllcloscd .01'en
In'tillitei ilor ,kiwi NoiM 01,t
i. I mal llroicct SLI'lAry 1:001,lcc111,1)