23 ABORN ST - BPA-10-89 ROOF The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
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Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
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Building Permit Application To Construct, Repair, Renovate Or Demolish a *Woftwktm
(� One- or Two-Famib,Dwelling
UV This Section For Official Use Only
Building Permit Number: (� Date Applied: n
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
l.t Prop^erty Address: 1.2 Assessors Map& Parcel Numbers ,
_Q" nrL,v
Ma Number Parcel Number
I.la Is this an accepted street?yes_ no
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1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq n) 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.40,134) 1.7 Flood Zone Information: - 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private ❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owneripf Record: {/ y Q 3 4 6c,
Name(Print) / �/N.A�`�� Address for Service:
Signature Telephone
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_Z,— I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S I. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: li
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su resgion
�] 00 Check No. _Check Amount: Cash Amount:
6, Total Project Cost: S I f�o ❑ Paid in Full ❑Outstanding Balance Due:
I
SECTION 5: CONSTRUCTION SERVICES I
5.1 Licensed Construction Supervisor(CSL) n 9 LI-7 L3
r \ 'V %j 6 S, License Number Expiration Date
Name of CSL- H Ider p List CSL Type(see below)
( q Ca,4ba
Address T e —nm .ion
U Unrestricted u to 35,000 Cu. Ft.)
Si R RestricMd I&2 Famd Dwellin
gnature
M lasonry Only
�. RC Residential Rooting Co
vering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC CompanYy,,Na a or HIC Re sirant Nr Registration Number
14 Yl�9Ar .i �G- �y.9b�rJ Y
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.¢ 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:OWNER' OR AUTHORIZED AGENT DECLARATION
1, 2y Gt b ZYCw`T ,as Owner o uthorized Agent ereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
T��nb ,.%s bt
Print Nam
S.gnatutree A of Owner or uthorized Agents Date
Signed under thepains and enalttes o r u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS, 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'