0008 1/2 ADAMS ST - BPA-12-771, TUB SURROUND, LALLY COL. �, I'he C'unununscuahh ul Massachuscits
1 Board of Building Regulations and Standards CITY OF
S,,LI:,I
Massachusetts
ssarhuseRs Slate Building Cute, 75U C'MR
Ashi
Building Permil Applic:Lion To Construct. Repair. Renovate Or De
One-ur Tnv:-l'i)mih• Duvellhnq
This Section For Official Use Only /
Building Permit Number: Date Applied: _
,
BBuilding011iciA tl'rint Mine) Stgna re ,
SECTION I: SITE INFORKIA ION
1.1 Property Address: 1.2 Assessors blap dr Parcel Numbers
I.la 13 this an accepted street? es no Map Number Parcel Nunll+cr
11.3 Zoning Inrormuflon: 1.4 Property Dimensions:
Lnning District Proposed Use Lot Arco(sy 11) Fronlage(11)
I.! Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Lune? Municipal❑ On site disposal slstum ❑
Check if cs❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
u v �a�S�a t) lyill k U S M_A.
Mi e(Print) City.Slaw,LIP
14�
No. J Street- A(���I.
Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check 0 that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repoirs(s) el Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Spccity:
rief Description of Proposed Work':_ \.
N
r �
SECTION 4: ESTLOATED CONSTRCiCTION COSTS
Ilan Estimated Costs: 0111c1u1 Use Only
11abur and ..\laterials)
1. Building S G G I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/To,on Application Fee
❑Tutai Project Cuser l Item 6).x multiplier _ x _
1. Plumhi"5 S ?. Other Fees. S
J. \lahanical ill\'.\(•) S List-_ -'_-- ---_-- �
�. \lech.mieal it Ire --
Cu ++ressionl S rotai \itFcvs: S
I, Total project Cost:
Check Nu. ('heck AnlUm me
l: C,tsh \n tir
-- —
�/ ❑ Pail in Full 13 Outstanding Bal;tnce Due:
StA I'ION S: CONS'I-RU(JION SFRVI('FS
5.1 ('onstruclion SuI)enisor Licen L1
-se(C'S
r— �u.1 . ----- - - -' /- -
1I�nsc Num7
ber Ptprull 'n Uam
None ol'C'Sl. 11uldcr n
r I ivt('St. I)pc Isec heloe K7(J_,y. - ']^QJG7 "A
Dcsaripliun
N, . .utd Street
qq���� (I I hvcstriclnJ t IIuilJin i a to 15,11111)ea I1.1
_ .! C7.LIC �_—.. . R Heetrwted Lr;? P.mtil Dttdlin
Cilyifattn,.' e, II' \I \lasso
RC Roolin C'otarin
K'S Window-uld 5 idin
anc
SF solid Fuel Ihtming Applie
'` s
l'dc hone Finail address U Demolition
5.2 Registered�I�lonAle�I�n�provenlent Contractor(HIC)
�C�`'J l�� Y"' � IIIC' Regisl� ralir li cpirntion Uutc
Mi. and Street 7_. ,^,3gP.�a& Email address
liA"N1J-J Prue.
tv/T;;�nlial;.ZIP C71 e. Tcle 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 Issuatocie of the building permit.
Signed Aflldavit Attached? Yes ..........Ild No...........O
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
Print 0%�ncr'3 Nwne(Elcctrunic Signature) Dale
SECTION 7b:OWNER' OR 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 my knowledge and understanding.
Prim Dancr's or Authuriied Agen'v Nunte IFkelrunic Signature) Date
NOTES:
I. An Otvncr who obtains a building permit to do his her own work,or an owner who hires an unregistered Contractor
(nut registered in the Hume Improvement Contractor(HICI Program),will rr) have access to the arbitration
program or guaranty Nod under.M.G.L.c. 1 4_2A. Other important information on the HIC Program can be found at
w.n. � % o, I Information on the Construction Supervisor License can be found at w%,% n,.l.,
2 \\'hen substantial stork is planned, provide the information below:
total (lour area(sq. R.I - ____.._1 including garage, finished basenent attics,decks or porch)
Grois lit ing area I iy. it.) _ _ _ _- , , Habitable room count
\umber of lifcplacci .. Number of bcdroomi .. .. . .
\umberol hathnwnts - . \uIlIM of,liall halts
h pe of hcoling i)<tcm Vunthcr of decks, pordtcs
I')pe al coollltg sy item I,ncloied ..OpCn
1. "fatal Proico Square Footage"may he iuhslittitcd litr"folol Project Cost" �