23-23R ABORN ST - BPA-09-609 RTN HOME TO 2 FAM, REMOVE 2 K&B'S i
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
i Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a
One- or Two-Fumill Duelling
Th ection For icial Use Only
Building Permit mbee Da Applied: (o�
Signature: - �—t
1 ) Building Commi - ner/Inspector o Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Number
X Z 3 - Z_3 �3 a�RAI ST S'ALrIM1 1!�A Map Number Parcel Number
1.1 a Is this an accepted street'?yes_ no
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage III)
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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if XesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of ReSohd:•
ug!r.�,,,•• d � 2g
t) l"� Address for Service: �t
Si aj'Lc Te e.,one
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(sX Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': 1PplPT �� O �j'�/b— F7�+,1,„f
y =MOVE2 S R
'A IQV45,—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
1N 3. Plumbing S 2. Other Fees: S r^�\
4. Mechanical (HVAC) S List: l
5. Mechanical (Fire S Total All Fees: $i
Su ression
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ❑ Paid in Full ❑ Outstanding Balance Due:
aosT
SECTION 5: CONSTRUCTION SERVICES `
5.1 Licensed Construction Supervisor(CSL)
' License Number Expiration Date
Ngmc of CSL- HQlder List CSL Type(sec below)
Address Type Description
U I Unrestricted(up to 35,000 Cu. Ft.)
Signature R Restricted I&2 Family Dwelling
M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning 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. 152.1 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.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
\ n OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
C S Z E P(I as Owner of the subject property hereby
authorize ( / IV U ) 1-79 to act on my behalf,in all matters
relative
4Owner
towork authorized by this building permit application.
St natur Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
z E/' H T ,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 Nune
Signature of Owner or Authorized Agent `'ry Date
(Signed under the pains and 2enalties ofperjury)
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 110.116 and 110.115, respectively.
L
n substantial work is planned, provide the information below:
ors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
ing area(Sq. Ft.) Habitable room count
of fireplaces Number of bedroomsof bathrooms Number of half/baths
eating system Number of decks/porches
ooling system Enclosed Open
l Project Square Footage"may be substituted forTTo[aa l�Pro]
ect Cost'
G � •